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OF  CALIFORNIA 

LOS  ANGELES 


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COLLECTANEA  JACOBI 

IN  EIGHT  VOLUMES 


Vols.  I,  II  and  HI,  Pediatrics 
Vols.  IV  and  V,  General  Thera- 
peutics AND  Pathology 
Vols.  VI  and  VII,  Important  Ad- 
dresses, Biographical,  and   His- 
torical Papers,  Etc. 
Vol.   VIII,   Miscellaneous    Arti- 
cles, Authors'  and  Complete  Top- 
ical Index 


DR.  JACOBI'S  WORKS 

COLLECTED  ESSAYS,  ADDRESSES, 
SCIENTIFIC  PAPERS  AND  MIS- 
CELLANEOUS WRITINGS 

OF 

A.  JACOBI 

M.   D.   UNIVERSITY  OF  BONN   (1851);   LL.   D.   UNIVERSITY  OF  MICHIGAN 

(1898),    COLUMBIA    (1900),    YALE    (1905),    HARVARD    (1906). 
Professor  of  Infantile   Pathology  and   Therapeutics   New  York  Medical   College 
(1860-1864);   Clinical  Professor  of  Diseases  of  Children,   New  York  University 
Medical  College   (1865-1869);  Clinical  Professor  of  Diseases  of  Children,  Col- 
lege  of   Physicians  and   Surgeons,    Columbia  University    (1870-1899) ;    Pro- 
fessor of  Diseases  of  Children  in  the  same   (1900) ;  Emeritus  Professor 
of  Diseases  of  Children  in  the  same  (1903);  Consulting  Physician  to 
Bellevue,    Mount    Sinai,    The    German,    The    Woman's    Infirmary, 
Babies',   Orthopedic,   Minturn  and  Hackensack  Hospitals. 
Member  of  the  New  York  Academy  of  Medicine  (1857),  Medical  Society  of  the 
City  and  County  of  New  York,   Medical   Society   of   the   State  of   New  York, 
Deutsche  Medizinische   Gesellschaft   of  New   York,    New    York   Pathological 
Society,    New   York   Obstetrical    Society,    Association   of   American    Physi- 
cians, American  Pediatric  Society,  American  Climatological  Association, 
Congress    of    American    Physicians    and    Surgeons,    American    Medical 
Association,  International  Anti-Tuberculosis  Association,  Association 
for  the  Advancement  of  Science;   Associate  Fellow  of  the  College 
of    Physicians    in    Philadelphia,    Soci6t6    de    Pediatric    de    Paris, 
Soci6t6  d'Obstetrlque,  de  Gynficologie  et  de  Pgdiatrie  de  Paris, 
American   Academy  of  Arts  and    Sciences;   Foreign  Member 
of    the    Gesellschaft    fiir    Geburtshiilfe    in    Berlin;    Corre- 
sponding     Member      Physicalisch-Medizinlsche       Gesell- 
schaft   of   Wiirzburg,  Gynecological  Society  of  Boston, 
Obstetrical   Society   of   Philadelphia,    Gesellschaft   fiir 
innere    Medizin    und   Kinderheilkunde    in    Wien. 
Honorary  Member  Yonkers  Medical  Association,  Louisville  Obstetrical 
Society,    Abingdon,    Va.,    Academy    of    Medicine,    Brooklyn    Medical 
Society,   Medical  Society  District  of  Columbia,  New  York  Obstet- 
rical   Society,    Medical    and    Chirurgical    Faculty    of    Maryland, 
American  Laryngological  Association,    Pediatric   Society  of  St. 
Petersburg,    Pediatric    Society    of    Kiev,    Royal    Academy    of 
Medicine,  Rome,  Deutsche  Gesellschaft  fur  Kinderheilkunde, 
Verein   fiir  Innere   Medizin    of   Berlin,    Royal   Society   of 
Medicine  of  Buda  Pesth. 


IN  EIGHT  VOLUMES 


EDITED   BY  WILLIAM  J.  ROBINSON,  M.D. 

NEW   YORK 

1909 


U     Icu^' 


I 


CONTRIBUTIONS 

TO 

PEDIATRICS 


BY 

A.  JACOBI,  M.D.,  LL.D. 
VOL.  I 

EDITED  BY  WILLIAM  J.  ROBINSON,  M.D. 


NEW    YORK 
THE   CRITIC   AND   GUIDE   COMPANY 

12  MT.  MORRIS  PARK  WEST 
1909 


Copyright,  1909, 
By    MARJORIE    McANENY 


Ubnuy 


to 

7 


3ln  iletttor^ 

of  grf at  anb  gnnb  mrn  long  Jippartfi, 
ritizf  n0  of  a  IjoapttabU  rountrg 

for  rottntlw0  fauora  unh  Ijonora  rfrttueii 

at  ti?r  tranJi0  of  roUragufa.  pttptla. 

aorwtifa    anb  uniufrattwa 

Jiuring  lyalf  a  r^nturg. 

A.  3(arobl 


809754 


AUTHOR'S    PREFACE 

To  My  Readers — If  there  be  any — I  desire  to  give 
an  explanation  of,  or  an  apology  for,  the  appearance 
of  these  volumes.  For  many  years  friends  have  en- 
couraged me  to  write  my  memoirs.  They  claimed  that 
the  Parc£E  had  not  cut  the  thread  of  my  life  only  to 
give  me  an  opportunity  to  report  what  I  had  observed 
in  connection  with  the  history  of  the  profession  of 
the  country  in  a  medical  practice  extending  over  al- 
most sixty  years,  as  a  public  teacher  of  medicine  dur- 
ing forty-five  years,  and  a  member  and  an  officer  in 
many  local,  national  and  international  associations. 
That  may  be  true,  but  as  a  memoir  writer  I  have  not 
succeeded  in  being  prolific  beyond  a  few  chapters 
which,  with  others,  may  or  may  not  reach  the  eyes  of 
my  friends,  and  enemies,  for  a  long  time  to  come,  if 
at  all.  A  very  good  reason  for  that  is  intelligible  to 
every  New  Yorker.  We  have  no  time  for  anything 
but  work ;  the  luxury  of  leisure  we  do  not  possess ;  and 
pleasure  is  enjoyed  only,  or  mostly,  by  those  who 
find  pleasure  in  work. 

So  no  memoirs  could  be  written,  on  account  of  con- 
stant, and  constantly  pressing  work.  Pegasus  wears 
no  harness,  and  I,  like  most  of  you,  have  always  been  in 
harness.  Whether  that  was  always  an  enjoyment  or 
a  benefit  to  others,  I  cannot  tell  you.  But  I  believe 
I  may  assure  my  present  readers  that  my  memoirs,  if 
they  ever  be  written,  will  prove  that  my  professional 

7 


AUTHOR'S    PREFACE 

life,  taken  all  in  all,  was  very  successful,  if  not  always 
lucky  or  happy. 

To  demonstrate  that,  a  few  reminiscences  may  be 
permitted  here ;  they  may  be  repeated,  amongst  others, 
posthumously,  may  be  ante-posthumously. 

The  first  of  my  professional  successes  was  the  fact 
that  it  took  my  first  patient  only  a  fortnight  after  my 
new  shingle  began  to  ornament  No.  20  Howard  street, 
to  call  on  me  with  his  twenty-five  cent  fee.  That  was 
in  November,  1853.  I  must  have  had  quite  a  reputation 
at  that  time,  for  his  only  excuse  for  coming  at  all  was 
that  he  had  heard  of  me.  I  think  I  must  have  gathered 
many  more  such  fees,  for  after  less  than  four  years  I 
was  one  of  the  founders  of  the  German  dispensary,  in 
which  treatment  was  strictly  gratuitous.  About  the 
same  time  of  this  memorable  achievement  of  mine.  Dr. 
Stephen  Smith,  that  good  and  glorious  man,  accepted 
from  me  a  long  series  of  extracts  from  European  jour- 
nals and  books,  mostly  on  diseases  of  children,  and 
within  another  year,  he  was  pleased  to  accept,  what  I 
am  still  pleased  to  call,  original  articles.  About  the 
same  time  my  inexperience  made  me  try  my  first  lecture 
on  half  a  dozen  suffering  students  (in  the  Spring 
course,  of  1857)  of  the  College  of  Physicians  and  Sur- 
geons. I  nearly  broke  down,  more  or  less  deservedly. 
My  subjects  were  the  diseases  of  the  young  larynx  and 
laryngismus  stridulus.  Nolens  volens  I  exhibited  in 
my  own  person  an  attack  of  laryngismus.  We  all  sur- 
vived. A  similar  experience  I  had  three  years  after- 
ward when  I  had  been  made  professor  of  infantile 
pathology  and  therapeutics  in  the  New  York  Medical 
College,  then  located  on  East  13th  Street.  If  some 
one  were  anxious  to  learn  how  I,  with  my  knowledge  of 

8 


AUTHOR'S    PREFACE 

pathology  and  therapeutics,  which  indeed  was  rather 
infantile,  became  a  professor,  this  is  how  it  happened. 
A  friend  of  mine,  who  has  a  tablet  of  liis  own  in  the  his- 
tory of  American  obstetrics,  had  taken  a  chair  in  the 
reorganized  school.  So  my  dear  Charles  Budd  wished 
me  to  go  in  with  him,  and  came  as  a  committee  to  offer 
me  a  place  in  the  faculty.  When  I  used  what  I  had 
of  common  sense  and  replied  that  I  did  not  feel  compe- 
tent, he  tried  his  great  art  on  himself.  He  delivered 
himself,  with  forcible  tongue,  of  so  many  uncomplimen- 
tary remarks  about  me,  that  I  accepted  his  terms  at 
once. 

The  very  next  year,  the  eighth,  I  made  a  heap  of 
money  out  of  literature,  which  is  remarkable  for  a  medi- 
cal man,  unless  he  be  Weir  Mitchell,  or  Osier,  or  Holt. 
It  happened  this  way, — ^perhaps  someone  wishes  to 
imitate  me.  Indeed,  I  believe  he  should.  In  1859,  E. 
Noeggerath  and  I  published  a  big  volume,  "  Contribu- 
tions to  the  Diseases  of  Women  and  Children,"  at  an 
expense  to  ourselves  of  $800;  a  few  years  afterward 
we  sold  the  edition  as  waste  paper  for  sixty-eight 
dollars,  a  clear  profit — compared  with  nothing. 

Thirteen  j^ears  passed,  and  I  suffered  from  fire ;  some 
rare  books  and  specimens  that  I  could  never  replace 
burned  down  with  the  University  Medical  College  build- 
ing on  Fourteenth  Street.  Over  the  ashes  of  my  prop- 
erty Tammany  Hall  was  erected,  which  refuses  to 
bum,  at  least  in  this  world.  About  the  same  time  I 
cashed  my  first  big  hospital  check  in  the  shape  of  a 
petechial  typhus,  of  which  I  got  well  after  public 
prayers  had  been  offered  by  some  good  old  ladies. 

After  seventeen  years,  I  scored  quite  a  success  when 
I — refusing  to  resign — got  myself  expelled  from  a  pub- 

9 


AUTHOR'S    PREFACE 

lie  institution  for  proving  a  hundred  per  cent,  mortality 
amongst  our  babies,  and  for  insisting  upon  a  farming- 
out  system.  Thus  things  have  been  going  on  for  years 
and  decades,  with  and  without  any  merit  of  mine.  Once, 
only  a  few  years  ago,  I  had  even  my  style  criticized, 
if  not  corrected.  There  was  a  gentleman  who  had  been 
working  for  a  hospital  thirty  years.  Then  the  matron 
found  fault  with  him,  and  vice  versa,  and  he  was  told 
that  he  would  be  permitted  to  resign,  if  he  could  not 
adapt  himself  to  the  lady.  He  resigned,  for  it  is  not 
everybody  that  prefers  to  be  expelled.  Thereupon,  and 
on  account  of  this  maltreatment  of  a  meritorious  officer, 
I  offered  my  resignation,  which  was  accepted  because 
the  tone  of  my  letter  was  declared  to  be  unpleasant. 

Such  specimens  of  the  practical  wisdom  of  other 
people  I  have  enjoyed  many  times.  Once  in  a  while  I 
had  (like  Jonathan  Swift)  to  write  or  talk  for  their 
betterment,  if  not  for  their  approval.  Thus  for  in- 
stance :  In  another  hospital  the  trustees  interfered  with 
the  mode  of  electing  medical  officers,  contrary  to  their 
own  by-laws,  which  they  might  have  altered  if  they  had 
waited  only  two  weeks.  But  they  were  in  such  a  hurry 
to  override  themselves  and  overturn  their  doctors !  So 
I  had  to  send  them  my  message  that  they  were  no 
longer  a  parliamentary  body,  and  also  my  resignation. 
In  the  course  of  a  long  life  I  have  scored  a  choice  lot 
of  successes  of  that  and  other  kinds,  but  after  all,  the 
definition  of  success  as  understood  by  different  people 
varies  very  greatly. 

Still  I  must  not  forestall  my  future  memoirs,  which 
must  be  expected  to  contain  many  experiences  not  al- 
ways of  a  pleasurable  order.  But,  at  least,  they  have 
been  instructive.     I  learned  from  them,  and  the  lessons 

10 


AUTHOR'S    PREFACE 

derived  from  them  have  benefited  me,  and  as  I  intended 
thej  should,  perhaps  others.  That  my  methods  were 
always  correct  or  politic,  I  do  not  say.  Indeed  I  am 
certain  that  if  I  had  displayed  more  patience  in  my  at- 
tempts at  improving  such  conditions  as  I  found  faulty 
or  defective,  I  might  have  been  more  successful  in  carry- 
ing my  points.  I  trust  my  mistakes,  some  of  which  may 
be  traced  in  a  number  of  papers,  may  interest  my 
friends  of  the  growing  generation.  They  may  remem- 
ber Cicero,  who  found  that  "  the  ears  of  the  masses  are 
dull,"  that  a  truth,  when  unpleasant,  requires  more  than 
a  single  promulgation.  Perhaps  the  revolutionary 
spirit  of  my  youth  and  a  warm  temperament  which 
boiled  at  a  low  temperature,  made  me  overlook  the  slow 
pace  at  which  reforms  are  established.  Reforms  re- 
quire alterations  of  opinions  and  tendencies,  and  or- 
ganic changes  are  of  slow  evolution.  Looking  back- 
wards forty  years,  I  can  imagine  that  the  very  ladies 
of  the  Nursery  and  Child's  Hospital,  like  the  trustees 
of  other  establishments,  impressed  with  their  good  in- 
tentions and  the  originality  of  their  positions,  elated 
by  the  financial  support  furnished  by  the  city  and  the 
State,  but  not  accustomed  to  attend  to  the  actual  work 
connected  with  financial  and  mortuary  records,  and  ad- 
verse to  be  taught  by  a  mere  doctor  who  proved  a  mor- 
tality in  their  institution  of  one  hundred  per  cent., 
could  have  been  with  a  certain  amount  of  diplomacy, 
made  glad  and  proud  of  improving  both  their  methods 
and  results.  My  old  papers,  rehearsed  in  one  of  these 
volumes,  will  tell  a  story  which  has  not  been  the  only 
one  since.  As  our  system  of  controlling  public  institu- 
tions has  not  met  with  radical  changes,  errors  of  ad- 
ministrations are  always  possible.     If  I  have  any  ad- 

11 


AUTHOR'S    PREFACE 

vice  to  give  to  my  colleagues  to  whom  much  is  given 
and  from  whom  much  is  demanded  in  their  connection 
with  public  affairs,  it  is  to  exhibit  more  patience  but  no 
less  firmness. 

But  I  forget  that  this  is  no  pulpit  or  platform.  My 
following  remarks  may  be  briefer.  The  friends  who 
urged  me  to  republish  old  papers  complained  of  their 
being  hidden  in  transactions  and  forgotten  magazines, 
and  regretted  that  half  of  them  were  never  reprinted, 
and  that  such  reprints  as  existed  at  all  were  not  acces- 
sible, except  in  a  few  large  libraries.  Some  were  more 
considerate  than  others.  They  wanted  me  to  publish 
merely  a  volume  or  two  of  my  therapeutic  papers.  So 
I  began  a  process  of  examining  and  sifting,  and  here 
is  the  result.  There  are  a  number  of  historical  studies. 
They  contain  facts  and  references  which  may  prove 
useful  to  those  who  are  in  need  of  them.  Indeed,  there 
are  persons  whose  historical  interests  are  not  limited 
to  what  has  happened  since  the  beginning  of  the  twen- 
tieth century.  Some  are  even  so  learned  as  to  quote 
others  besides  themselves  and  their  friends.  An  objec- 
tive report  of  historical  facts  should  always  be  welcome. 
The  history  of  medicine  is  neglected  amongst  us.  Only 
of  late  we  hear  of  an  occasional  course  of  lectures  on 
this  most  important  subject,  and  I  know  of  no  profes- 
sorship, not  even  lectureship,  on  the  history  of  medicine 
in  our  schools. 

With  the  exception  of  a  single  quarterly  journal 
devoted  to  the  history  of  medicine,  we  have  only 
John  Watson's  "  The  Medical  Profession  in  An- 
cient Times,"  1856;  "  The  Nose  and  Throat  in  Medical 
History,"  by  Jonathan  Wright;  Alvin  A.  Hubbell's 
"The    Development    of   Ophthalmology    In    America," 

12 


AUTHOR'S    PREFACE 

1800-1870,  1908;  Samuel  D.  Gross  "Lives  of  Eminent 
American  Physicians  and  Surgeons,"  1861 ;  "  A  Century 
of  American  Medicine,"  by  Clarke,  Bigelow,  Gross, 
Thomas  and  Billings,  1876;  the  valuable  works  of  Pack- 
ard and  Mumford,  and  a  very  few  others  (Roswell 
Park,  N.  S.  Davis).  We  have  no  systematic  attempts 
at  writing  up  ancient,  modem,  or  our  own  medical 
history. 

The  history  of  diphtheria  is  illuminated  in  a  number 
of  my  papers.  I  have  seen  the  scourge  since  1858,  and 
written  about  it  many  times  since  I860,  thus  embodying 
our  advancing  knowledge  on  the  subject  until  to-day. 
The  clinical  description  has  not  made  much  progress 
these  many  decades.  Therapy,  however,  has  changed 
wonderfully.  O'Dwyer's  intubation  rendered  tracheo- 
tomy almost  obsolete — indeed,  after  seven  hundred 
tracheotomies  of  my  own  I  have  had  no  opportunity  to 
operate  since  O'Dwycr;  and  Behring's  antitoxin  has 
reduced  the  mortality  to  one-third.  That  the  anti- 
toxin is  useless  in  the  very  worst  of  septic  cases,  is 
pitiful;  still  more  pitiful  is  the  fanaticism  of  all  pos- 
sible sexes  which  objects  to  the  bold  use  of  alcohol,  the 
best  of  antiseptics  in  these  desperate  and  otherwise 
hopeless  cases. 

In  many  of  my  addresses,  those,  who  will  look  for 
them,  may  find  many  facts  connected  with  the  establish- 
ment of  pedriatics  as  a  special  study  and  a  subject  of 
special  teaching.  It  is  a  delight  to  know  that  beside 
J.  Lewis  Smith,  Rotch,  Holt,  Huber,  Griffith,  Koplik, 
Northrup  and  Forchheimer  there  are  scores  of  younger 
men  who  are  forming  what  may  be  termed  an  American 
school  of  Pedriatics. 

The   development   of  institutions,   such   as   the  New 

13 


AUTHOR'S    PREFACE 

York  Academy  of  Medicine,  the  Societies  of  the  City 
and  County,  and  State  of  New  York,  of  libraries,  and 
of  national  and  international  congresses  will  also  be 
found  alluded  to,  or  discussed.  At  all  events  I  believe 
that  an  attentive  reader  will  be  rewarded  by  much 
useful  material.  A  number  of  cases  reported  dozens 
of  years  ago,  have  never  lost  for  me  the  interest  I  took 
in  them  when  they  were  first  observed.  I  hope  that  my 
many  talks  on  the  principles  of  medical  ethics  will 
coincide  with  the  opinions  of  most  of  my  readers.  The 
moral  groundwork  of  a  gentleman's  feelings  and  be- 
havior was  always  the  same,  through  centuries  man's 
heart  has  always  been  human,  only  tastes  differ  and 
usually  in  trifles.  Whether  the  profession  of  America 
will  always  object  to  a  physician  taking  out  a  patent 
I  do  not  know.  They  permit  it  in  Europe.  Whether 
we  shall  always  object  to  a  man  printing  his  actual 
or  pretended  specialty  on  his  shingle  or  his  card,  I 
cannot  know.  They  do  it  in  Europe ;  but  I  trust,  we 
shall  always  deem  it  objectionable,  as  soliciting  pre- 
sumptuousness  or  lack  of  taste.  But  these  things  show 
perhaps  only  absence  of  judgment,  but  no  lack  of  heart 
and  conscience.  But  that  there  are  men  in  the  pro- 
fession who  give  or  demand  bribes,  take  "  commissions  " 
from  apothecaries,  instrument  and  bandage  makers, 
nurses, — men  and  women — manufacturers,  in  the  shape 
of  cash  or  stock,  consultants  both  medical  and  surgi- 
cal— that  is  no  longer  professional,  no  longer  even 
the  competition  of  an  honest  tradesman :  it  is  robbery, 
which  pollutes  the  moral  atmosphere  of  professional 
life,  and  fleeces  the  consumer  of  your  services,  i.  e. 
the  patient. 

My  views  regarding  the  principles  of  therapy,  both 

14. 


AUTHOR'S    PREFACE 

hygienic  and  medicinal,  I  tinist  are  agreeable  to  those 
who  live  a  modern  life,  without  superstitious  belief  in 
things  because  they  are  old,  and  without  faith  in  the 
new  stuffs  merely  because  they  are  new. 

Many  papers  and  addresses  contain  my  views  con- 
cerning the  most  important  and  momentous  question  at 
all  times  and  before  all  nations,  viz :  the  feeding  of  in- 
fants. If  the  problem  were  settled  to  everybody's  sat- 
isfaction, it  would  not  be  necessary  to  speak  again  at 
this  place.  It  is  a  satisfaction  however  to  know,  that 
modern  physiology  and  biochemistry  have  not  changed 
the  practical  teaching  furnished  me  by  domestic  and 
clinical  observations  these  more  than  fifty  years.  That 
a  number  of  men  high  in  our  ranks  are  joining  me 
quietly  and  unostentatiously  in  giving  the  babies  a 
fighting  chance  against  overdone  theories  and  detri- 
memtal  practices  of  notoriety-seeking  persons,  iis  a 
source  of  congratulation.  Long  may  they  live,  I 
mean  the  babies.  Those  friends  of  mine  and  of  all  the 
babies  are  not  the  ones  you  so  often  meet-  In  connec- 
tion with  interviews,  haphazard  telephone  conversations 
and  reports  of  cases  In  the  daily  papers.  They  are 
clever  enough  to  avoid  being  called  in  the  public  col- 
umns "  expert  in  the  diseases  of  children,"  "  famous 
professor  of  pediatrics,"  and  what  not.  Indeed  these 
short-sighted  people  prefer  to  make  an  honest  reputa- 
tion of  their  own — and  they  succeed. 

In  regard  to  the  discussion  of  medical  and  sanitary 
problems  in  the  daily  press,  our  views  may  not  always 
agree.  It  Is  customary  to  extol  It,  like  the  stage,  and 
the  pulpit,  as  the  indispensable,  omniscient  and  moral 
and  most  influential  power.  I  mean  to  join  in  that 
praise-^of  its  possibilities,  but  I  think  we  could  add 

15 


AUTHOR'S    PREFACE 

to  its  indispensability,  omniscience,  moral  power  and 
influence,  without  the  necessary  commission  of  many 
mistakes  on  the  part  of  an  uninformed,  though  ever 
so  bright  news-hunting,  reportorial  staff.  What  I 
have  occasionally  proposed  was  this,  that  a  great 
paper  should  have  on  its  editorial  staff  a  thorough 
medical  man  whose  whole  or  most  of  whose  work  should 
be  dedicated  to  the  study  and  discussion  of  popular 
medicine  and  sanitation  in  all  its  branches.  Give  him 
a  large  salary  and  be  sure  you  will  strike  a  cheap  bar- 
gain by  paying  him  well.  At  that  rate  your  paper 
will  secure,  for  ten  thousand  dollars  a  year,  a  reliable 
report  and  sound  criticism  of  what  you  and  your  pub- 
lic is  anxious  and  entitled  to  learn. 

A  still  better  plan  is  this.  In  matters  of  political 
and  social  importance  hundreds  of  newspapers  have 
their  central  bureau,  the  Associated  Press.  The 
newspapers  of  the  country  should  have  their  cen- 
tral bureau  of  sanitation  and  preventive  medicine.  Let 
them  spend  as  much  money  on  this  center,  say  thirty 
or  fifty  thousand  dollars,  or  more, — as  much  as  a  single 
large  life  insurance  company  spends  for  a  medical  staff, 
for  its  commercial  purposes.  At  that  rate  the  papers 
can  procure  whatever  knowledge  there  is,  both  old  and 
new,  and  may  at  once  become  what  they  wish  to  be, 
and  wish  to  be  credited  with,  and  deserve  to  be, — foun- 
tains of  popular  science,  teachers  of  the  people,  found- 
ers of  a  more  intelligent,  better  informed,  and  healthier 
nation.  The  central  bureau  should  be  for  all,  furnish 
equal  information  for  all,  both  for  the  people  and  its 
governments,  without  the  dangers  of  grave  mistakes, 
misleading  sensationalism  and  corrupting  competition. 

I  should  add  a  few  words  in  regard  to  myself  and 

16 


AUTHOR'S    PREFACE 

the  editor  of  these  volumes.  Dr.  WiHiam  J.  Robinson 
has  been  my  critic  and  guide.  If  I  have  fault  to 
find  with  him  it  is  that  as  a  critic  he  was  too  lenient. 
It  gave  him  evident  pleasure  to  republish  whatever 
appeared  to  contribute  to  the  demonstration  of  the 
life-evolution  of  a  man  whose  public  utterances  seemed 
to  him  to  furnish  some,  though  ever  so  slight,  addi- 
tions to  the  scientific,  mental  and  ethical  acquisitions 
of  the  medical  profession  and  its  stanching  in  the 
commonwealth.  Being  a  good  citizen  himself,  a  de- 
termined adversary  of  doubtful  or  wrong  practices 
amongst  us,  a  strenuous  fighter  against  past  and  pres- 
ent evils  and  in  favor  of  a  right-minded,  strictly  scien- 
tific and  ethical  future,  he  thought  he  met  in  my  writ- 
ings a  congenial  spirit  and  sympathetic  though  modest 
ally.  That  is  why  he,  though  occupied  with  the 
duties  of  a  medical  practice  and  the  editing  and  prac- 
tical creation  of  three  scientific  journals — including  his 
epoch-making  "  Critic  and  Guide  " — has  burdened 
himself  with  the  arranging,  editing,  printing,  proof- 
reading, translating,  indexing,  binding,  indeed  every- 
thing connected  with  the  production  of  these  volumes. 
If  there  be  any  merit  in  them  it  is  his ;  if  the  books  lead 
to  any  praiseworthy  results,  the  credit  belongs  to 
him. 

19  East  47th  Street.  A.  Jacobi. 


17 


EDITOR'S    PREFACE 

I  KNOW  of  no  other  man,  either  among  the  living 
or  among  those  who  have  passed  on,  who  in  our  country 
has  had  such  an  important  influence  on  the  develop- 
ment of  medicine  in  all  its  phases,  as  has  Dr.  Abraham 
Jacobi  of  New  York.  The  adjective  important  is, 
however,  not  adequate  nor  quite  satisfactory.  An 
influence  may  be  important,  and  yet  not  beneficial;  or 
it  may  be  only  partially  beneficial,  and  it  is  sometimes 
a  vexed  problem  to  determine  whether  a  man's  influ- 
ence has  been  more  beneficial  than  harmful  or  vice 
versa.  No  such  problem  confronts  us  in  estimating 
the  activity  of  Dr.  Jacobi.  For  his  influence  has  been 
wholly  for  the  good,  for  the  highest  good  both  of  the 
profession  and  of  humanity.  Bear  this  last  word  in 
mind.  For  great  as  Dr.  Jacobi  is  as  a  physician, 
great  as  a  teacher,  great  as  an  investigator,  he  is 
equally  great  as  a  humanitarian.  Not  here  is  the  place, 
nor  is  mine  the  ability  to  speak  of  Dr.  Jacobi's  ser- 
vices to  medicine  proper ;  of  his  services  to  pediatrics ; 
of  the  debt  the  little  children  the  world  over  owe  and 
forever  will  owe  him;  of  the  thousands  of  lives  that  he 
has  saved  personally;  nor  will  I  dilate  here  upon  the 
indebtedness  the  profession  owes  him  for  holding  aloft 
■  and  lighting  its  path  with  the  torch  of  therapeutic  op- 
timism in  the  midst  of  the  stark-darkness  of  thera- 
peutic pessimism  and  despair;  nor  will  I  speak  here 
of  his  services  in  having  brought  American  and  Euro- 

19 


EDITOR'S    PREFACE 

pean  medicine  closer  together,  his  services  in  making 
us — those  of  us  who  deserve  to  be  respected — respected 
abroad.  I  hope  that  all  this  will  be  adequately  and 
properly  done  in  another  place  by  an  abler  pen  than 
mine.  What  I  want  to  allude  to  here  is  Jacobi,  the 
physician-man.  Jacobi  belongs  to  the  noble  few  who 
have  perceived  that  the  dispensing  of  pills,  powders 
and  decoctions  is  not  the  physician's  only  function, 
nor  even  his  highest  function.  He  belongs  to  the  noble 
few  who  many  years  ago  perceived  that  many  diseases 
had  a  social-economic  basis,  and  that  if  we  wanted  to 
do  any  good  we  had  to  improve  the  economic  and  sani- 
tary conditions  of  the  people.  And  this  he  preached 
at  every  opportunity — even  when  his  preaching  was 
not  welcome.  He  belongs  to  the  noble  few  who  regard 
the  physician's  role  as  something  more  than  that  of  a 
reliever  of  aches  and  pains — he  perceived  the  role  of 
the  physician's  role  as  something  more  than  that  of  a 
sanitarian,  a  preventer,  a  critic,  a  guide.  And  while 
he  has  sometimes  been  a  severe  critic,  he  has  always 
been  willing  and  ready  to  act  as  a  guide.  And  his 
guidance  has  always  been  a  safe  and  reliable  one. 

What  attracted  me  to  Dr.  Jacobi  long  before  I  had 
the  pleasure  of  his  personal  acquaintance  was  his  sturdy 
honesty,  his  rugged  fearlessness,  which  one  could  read- 
ily feel  in  his  public  speeches  and  addresses.  He  never 
missed  an  occasion  to  inculcate  a  wholesome  lesson. 
And  he  was  never  afraid  of  his  audience.  Where  an- 
other person  would  pour  out  fulsome,  cloying  praise, 
he  would  offer  healthy  criticism;  where  another  per- 
son would  dispense  nothing  but  taffy,  Dr.  Jacobi 
would  present  a  good  dose  of  Epsom  salt ;  to  dispense 
undeserved  flattery  has  always  been   as  distasteful  to 

20 


EDITOR'S    PREFACE 

him  as  to  receive  it.  And  if  his  audience  did  not  like 
some  of  the  wholesome  but  bitter  truths  that  he  gave 
them,  why,  he  just  let  them  dislike  them.  His  ad- 
dresses, at  the  various  annual,  decennial,  semi-centen- 
nial and  centennial  celebrations,  his  presentation  and 
banquet  speeches,  are  very,  very  many  in  number.  I 
have  read  them  all,  and  I  cannot  think  of  one  which 
could  be  characterized  merely  as  a  conglomeration  of 
nice,  soft  words,  of  adulatory,  obsequious,  flattering 
phrases ;  there  is  not  one,  as  far  as  I  remember,  that 
does  not  contain  some  gentle  satire  (or  one  perhaps  not 
quite  so  gentle)  on  our  foibles  and  failings,  on  our 
egotism,  on  our  desire  to  seem  what  we  are  not,  on  our 
sins  of  omission  and  commission.  By  his  frank  speeches 
he  lias  made  some  enemies — well,  we  love  him  for  the 
enemies  he  has  made. 

The  entire  history  of  American  medicine  during  the 
past  half  century — is  reflected  in  Dr.  Jacobi  and  in 
his  writings.  Not  only  has  he  been  a  faithful  chron- 
icler, but,  what  is  more  important,  he  has  been  to  a 
great  extent  the  maker  of  this  history.  He  has  kept 
tab  on  the  progress  of  medicine  in  every  one  of  its 
branches,  and  he  has  always  kept  step  with  the  pro- 
cession. Often,  very  often,  we  find  him  in  the  van- 
guard, but  never,  never  in  the  rear,  never  among  the 
laggards.  And  he  who  wants  to  know  the  history  of 
medicine  in  America  during  the  past  half  century,  must 
read  the  writings  of  A.  Jacobi.  Therein  he  will  find 
expressed  its  hopes  and  disappointments,  its  progress 
and  backward  movement ;  every  step  leading  to  the 
elevation  of  the  profession  he  will  find  therein  praised 
and  encouraged,  while  every  step  tending  to  degrade 
our  great  profession,  every  step  leading  to  falsehood, 

21 


EDITOR'S    PREFACE 

hypocrisy,  mediocrity  and  commercialism  has  been 
scorched  by  him  in  no  uncertain  terms.  Excellent  as 
is  the  quality  of  Dr.  Jacobi's  writings,  their  quantity 
no  less  excites  our  admiration.  Especially  so,  when 
we  recollect  that  he  has  not  rehashed  any  text-books 
and  then  published  them  as  his  own,  and  that  he  has 
never  written  because  of  an  unquenchable  cacoethes 
scribendi.  No,  Dr.  Jacobi  writes  only  when  he  has 
something  to  write  and  he  speaks  only  when  he  has 
something  to  say.  Unfortunately  many  of  his  essays 
and  papers  have  been  hidden  away  in  periodicals 
which  are  not  readily  accessible,  or  in  society  transac- 
tions which  are  altogether  inaccessible ;  some  of  his 
addresses  have  never  been  published,  and  others  have 
been  delivered  or  written  in  German.  Some  of  the  ad- 
mirers of  Dr.  Jacobi,  among  whom  I  most  emphatically 
count  myself,  have  thought  it  a  great  pity  to  have  so 
many  of  his  excellent,  important  and  even  epoch-mak- 
ing writings  become  practically  lost.  They  thouglit  it 
an  injustice  to  Dr.  Jacobi  and  a  sin  against  posterity. 
Dr.  Jacobi  was  approached  on  the  subject.  With  the 
modesty  of  true  greatness  he  could  not  see  it  our  way. 
He  did  not  think  that  his  writings  were  really  of  such 
importance,  etc.  Finally  he  was  prevailed  upon.  And 
I  have  been  honored  with  the  task  of  selecting, 
editing,  arranging,  translating  and  preparing  for  the 
printer  the  enormous  mass  of  the  material  of  which 
Dr.  Jacobi  is  the  author.  The  task  seemed  an  enor- 
mous one,  but  no  task  is  difficult  into  which  you  put 
some  love.  How  I  have  acquitted  myself  of  this  labor 
of  love,  I  leave  others  to  judge. 

The  arrangement  of  the  matter  is,  as  far  as  feasible, 
both  by  subjects   and  chronological,  but  no  pedantic 

22 


EDITOR'S    PREFACE 

rule  has  been  followed.  A  more  or  less  logical  arrange- 
ment seemed  to  us  the  best. 

In  writings  extending  over  a  period  of  over  a  half  a 
century,  some  repetition  is  unavoidable.  To  minimize 
this,  the  articles  have  in  some  cases  been  condensed. 
Others  have,  on  account  of  their  historical  value,  been 
considered  too  important  to  admit  of  their  abbrevia- 
tion or  condensation  in  any  way.  And  it  was  consid- 
ered much  better  to  incur  the  risk  of  occasional  repe- 
tition than  to  run  the  danger  of  eliminating  and  losing 
a  single  historically  or  scientifically  valuable  sentence. 

For  the  sake  of  historical  fidelity,  it  has  seemed 
best,  as  a  rule,  to  leave  the  spelling  and  the  nomen- 
clature as  they  appeared  originally.  We  will  therefore 
meet  in  these  volumes :  anaemia  and  anemia,  haemor- 
rhage and  hemorrhage,  peritonaeum  and  peritoneum, 
hypermanganate  of  potassa  and  potassium  perman- 
ganate, hydrochlorate  of  ammonia  and  ammonium 
chloride,  therapeutical  and  therapeutic,  etc.,  etc.  The 
author  has  kept  pace  both  with  the  simplified  spelling 
and  the  constantly  changing  pharmacopeial  nomen- 
clature. 

May  these  volumes  which  we  trust  will  remain  a 
monument  of  Dr.  Jacobi's  varied  activity  aere  peren- 
nius — more  permanent  than  bronze — also  serve  as  an 
inexhaustible  source  of  inspiration  to  the  profession 
of  our  country,  the  profession  which  Dr.  Jacobi  has 
loved  so  well,  the  profession  which  in  spite  of  its  im- 
perfections remains  the  noblest  of  all  professions ! 

William  J.  Robinson. 

12  Mt.  Morris  Park   W. 

23 


CONTENTS 

VOLUME    I 

AUTHOR'S    PORTRAIT    (Steel    plate)       .      .      .     Frontispiece 

AUTHOR'S  PREFACE 7 

EDITOR'S   PREFACE 19 

TABLE   OF  CONTENTS 25 

INTRODUCTORY   CHAPTER          27 

From    Keating's    "  Cyclopaedia    of    the    Diseases    of 

Children,"    Vol.   I. 

THE    RELATIONS    OF    PEDIATRICS    TO    GENERAL 

MEDICINE 41 

Address  delivered  before  the  American  Pediatric 
Society  at  Washington,  D.  C,  September  20,  1889. 
Archives    of,   Pediatrics,   November,    1889. 

THE    HISTORY    OF    PEDIATRICS    AND    ITS    RELA- 
TION TO  OTHER  SCIENCES  AND  ARTS      ...       55 
Address   delivered   before   the   Congress   of   Arts   and 
Sciences,  St.  Louis,  Mo.,  September  21,  1904.    Ameri- 
can Medicine,  November,  1904. 
THE   HISTORY  OF  CEREBRO-SPINAL  MENINGITIS 

IN  AMERICA 95 

Transactions  of  the  Medical  Society  of  the  State  of 
New  York,  1905. 

CEREBRO-SPINAL        MENINGITIS:        SYMPTOMA- 
TOLOGY   AND    TREATMENT 107 

Part  of  a  paper  read  before  the  Deutsche  Medicinische 
Gesellschaft  der  Stadt  New  York.  New  Yorker  Medi- 
cinische Monatsschrift,  April,  1905.  Translated  from 
the  German.  The  history  of  Cerebro-Spinal  Menin- 
gitis and  the  mortality  statistics  of  the  disease  have 
been  omitted  from  this  article,  as  they  are  dealt  with 
adequately  in  the  preceding  paper. 
DIPHTHERIA:         ITS       SYMPTOMATOLOGY       AND 

TREATMENT 121 

From    "  The    Twentieth    Century    Practice    of    Medi- 
cine." 
THE  PATHOLOGY  AND  TREATMENT  OF  THE  DIF- 
FERENT  FORMS   OF   CROUP 213 

Read   before   the   Medical   Society   of  the   County   of 
New  York.     American  Journal  of  Obstetrics,  Diseases 
of  Women  and  Children,  May,  1868. 
25 


CONTENTS 

CHOLERA    INFANTUM        253 

From  "  The  Twentieth  Century  Practice  of  Medi- 
cine." 

TYPHOID  FEVER  IN  THE  YOUNG 293 

Read  before  New  York  State  Medical  Society, 
October  25,  1899.     Pediatrics,  Vol.  VIII.,  No,  12. 

ANEMIA   IN   INFANCY   AND   EARLY   CHILDHOOD     333 
Read  before  Medical  Society  of  the  County  of  New 
York,    December    27,    1880.      Archives    of   Medicine, 
Vol.  v.,  No.  1,  1881. 

TREATMENT  OF   INFLUENZA   IN  CHILDREN      .      .     347 
Part  of  a  paper  read  before  the  Medical  Society  of 
the    County    of    New    York,     November    26,    1900. 
Medical  News,  December  15,  1900. 

OTITIS    MEDIA    IN    CHILDREN      .     .     .     .     .     .     .357 

Read  before  the  New  York  Academy  of  Medicine 
under  auspices  of  the  Section  on  Otologj',  Decem- 
ber,  1904.     Archives  of   Otology,  No.   2,  i905. 

NEPHRITIS  OF  THE  NEWBORN 369 

Read  before  the  Medical  Society  of  the  District  of 
Columbia,  November  28,  1895.  New  York  Medical 
Journal,  January  18,  1896. 

THE  PREVENTION  OF  TUBERCULOSIS  IN  SCHOOL 

CHILDREN 393 

Lecture  delivered'  before  Teacher's  College,  New 
York.     Teacher's  College  Record,  March,  1905. 

CAUSES  OF  EPILEPSY  IN  THE  YOUNG     ....     411 
Read  before  the  National  Association  for  the  Study 
of  Epilepsy,  November  5,  1902.     American  Medicine, 
December  13,  1902. 

TREATMENT   OF   ENURESIS 431 

From  Keating's  "  Cyclopaedia  of  the  Diseases  of 
Children,"  Vol.  III.  " 

RACHITIC    DEFORMITIES:    ETIOLOGY,    CLINICAL 

HISTORY    AND   LESIONS 439 

A  discussion  at  the  meeting  of  the  American  Ortho- 
pedic Association  at  Washington,  D.  C,  May  30,  1894. 
Stenographic  report.  Archives  of  Pediatrics,  Sep- 
tember, 1895. 

26 


INTRODUCTORY    CHAPTER  * 

Upon  me  has  been  conferred  the  honor  of  introducing 
to  the  medical  public  the  essays  of  all  the  distinguished 
men  contributing  to  this  great  work.  Though  with  some 
hesitation^  it  is  with  still  more  satisfaction  that  I  comply 
with  this  demand.  For  the  very  enterprise  marks  an  im- 
mense progress  in  the  history  of  both  general  medical  and 
pediatric  literature.  Indeed,  when  I  began  my  profes- 
sional life,  such  a  collection  of  monographs  as  will  here 
be  offered  could  not  have  been  written.  Now,  that  during 
a  single  generation  there  should  have  been  such  a  thorough 
change  in  the  methods  of  both  medical  thought  and  work, 
is  a  source  of  the  most  intense  gratification,  as  well  to  me 
as  to  every  other  man  who  has  absolute  faith  in  the  per- 
sistent evolution  of  science  and  the  improvement  of  the 
race. 

That  there  should  be  any  doubt  as  to  the  propriety  of 
a  large  special  work  on  the  diseases  of  children,  I  can 
hardly  believe  in  the  present  stage  of  development  of 
American  medical  literature.  As  far  as  I  am  concerned, 
I  never  objected  to  being  found  among  the  adversaries 
of  the  wildfire  of  specialism  which  has  been  spreading 
among  the  groups  of  medical  men.  On  the  contrary,  I 
am  still  of  the  opinion  I  expressed  eight  years  ago  when 
I  opened  the  first  session  of  the  Section  on  Diseases  of 
Children,  of  the  American  Medical  Association,  at  its 
meeting  at  New  York. 

With  more  pertinacity  than  logic,  pediatrics  (compre- 
hending; the  anatomy,  physiology,  pathology,  and  thera- 
peutics of  infancy  and  childhood)  has  also  been  claimed 
as  a  specialty.  This  is  a  mistake,  however,  which  has 
been  made  more  frequently  on  the  continent  of  Europe 
than  with  us.      It  is  there  that  practitioners   and   authors 

[  *  This  formed  the  Introductory  chapter  to  Keating's  "  Cyclo- 
paedia of  the  Diseases  of  Children."  It  has  seemed  appropriate 
to  use  it  as  the  introductory  chapter  to  the  volumes  on  Pedi- 
atrics.— Editor.] 

27 


DR.    JACOBI'S    WORKS 

advertise  themselves,  for  reasons  of  their  own  which  would 
not  be  approved  of  here,  as  "  children's  physicians  "  and 
"  specialists."  Pediatrics,  however,  is  no  specialty  in  the 
common  acceptation  of  the  term.  It  does  not  deal  with  an 
organ,  but  with  the  entire  organism  at  the  very  period 
which  presents  the  most  interesting  features  to  the  student 
of  biology  and  medicine.  Infancy  and  childhood  are  the 
links  between  conception  and  death,  between  the  foetus 
and  the  adult.  The  latter  has  attained  a  certain  degree 
of  invariability.  His  physiological  labor  is  reproduction, 
that  of  the  young  is  both  reproduction  and  growth.  As 
the  history  of  a  people  is  not  complete  with  the  narration 
of  its  condition  when  established  on  a  solid  constitutional 
and  material  basis,  so  is  that  of  man,  either  healthy  or 
diseased,  not  limited  to  one  period.  Indeed,  the  most 
interesting  time  and  that  most  difficult  to  understand  is 
that  in  which  a  persistent  development,  increase,  and  im- 
provement are  taking  place. 

This  appears  to  have  been  felt,  instinctively,  from  the 
very  beginning.  The  history  of  pediatrics,  therefore,  is 
as  old  as  that  of  medicine.  Their  literatures  have  developed 
uniformly,  from  superstitious  beliefs  to  empirical  state- 
ments and  the  methodical  researches  of  the  present  time. 
The  last  centuries,  particularly  the  last  decades,  are  re- 
plete with  text-books  on  the  diseases  of  children,  mono- 
graphs on  their  pathology,  physiology,  and  hygiene,  and 
journals,  quite  a  number  of  which  are  now  published  in 
the  four  principal  languages  of  the  civilized  world. 

These  monographs  and  journals  have  contributed  a  great 
deal  to  the  amount  of  medical  knowledge.  Special  re- 
searches of  the  normal  condition  of  embryonic,  foetal,  and 
infant  growth,  the  study  of  the  functions  of  the  organs 
in  their  constant  development  and  changes,  and  anatomical 
and  clinical  investigations,  have  contributed  to  prove  that 
pediatrics  does  not  deal  with  miniature  men  and  women, 
with  reduced  doses  and  the  same  class  of  diseases  in  smaller 
bodies,  but  that  it  has  its  own  independent  range  and  hori- 
zon, and  gives  as  much  to  general  medicine  as  it  has  re- 
ceived from  it. 

There  is  scarcely  a  tissue,  or  an  organ,  which  behaves 

28 


INTRODUCTORY  CHAPTER 

exactly  alike  in  the  different  periods  of  life.  The  bones 
contain  less  phosphates  in  the  young  and  exhibit  other 
chemical  differences,  their  anatomical  structure  is  differ- 
ent, their  increase  less  periosteal,  than  in  advanced  years. 
The  cartilaginous  condition  of  the  epiphyses  gives  rise  to 
a  number  of  disorders ;  the  cartilages  between  the  epiphy- 
ses and  diaphyses  are  subject  to  all  forms  of  disease,  from 
a  simple  irritation  resulting  in  abnormal  growth  (for  in- 
stance, after  eruptive  fevers)  to  a  separation,  by  suppura- 
tion, of  the  epiphyses.  There  is  hardly  a  chapter  more 
interesting  than  that  of  the  relation  of  the  bones  of  the 
cranium  to  its  contents.  A  solid  skull  serves  as  a  sup- 
port to  the  brain  and  its  blood-vessels,  or  it  may  prove 
an  obstacle  to  their  development;  an  insufficient  degree  of 
ossification,  and  an  undue  amount  of  sutural  substance,  will 
enhance  the  possibility  of  enlargement  of  the  blood-vessels 
and  the  liability  to  effusion.  Premature  ossification,  how- 
ever, either  partial  or  general,  is  a  cause  of  asymmetry, 
epilepsy,  or  idiotism,  and  influences  the  course  of  inter- 
current diseases.  The  large  size  of  the  head,  which  is 
equalled  by  that  of  the  thorax  about  the  middle  or  the  end 
of  the  third  year  only,  is  in  close  relation  to  the  physio- 
logical growth  of  the  brain  and  its  pathological  changes. 
The  veterbral  column  is  quite  flexible,  but  straight,  and 
mainly  so  in  its  upper  portion.  Its  very  flexibility  is  a 
ready  cause  of  the  frequent  occurrence  of  scoliosis.  Its 
distance  from  the  manubrium  sterni  is  so  small  that  oc- 
casionally a  thymus,  and  frequently  enlarged  lymph-bodies, 
are  a  cause  of  irritation  or  compression.  The  base  of  the 
thorax  is,  however,  relatively  wide,  while  its  height  is 
less.  This  becomes  particularly  striking  by  the  almost  rec- 
tangular insertion  of  the  ribs  at  the  transverse  processes 
of  the  vertebrae  and  the  sternum,  and  by  their  almost  hori- 
zontal and  circular  position  by  which  the  respiration  be- 
comes less  costal,  and  the  viscera  of  the  abdominal  cavity, 
mainly  the  liver,  appear  more  prominent.  Changes  of  a 
pathological  character  are  quite  frequent  about  this  time, 
and  a  frequent  cause  of  disease  in  later  life.  Hueter's 
researches  on  the  congenital  contraction  of  the  chest,  and 
Freund's  investigations  on  the  premature  ossification  of  the 

29 


DR.    JACOBI'S    WORKS 

costo-cartilaginous  junctures,  are  exceedingly  important,  in- 
asmuch as  they  explain  many  of  the  isolated  cases  of 
thoracic  insufficiency,  phthisical  habitus,  and  pulmonary  in- 
competency. 

The  nervous  system  of  the  young  is  but  in  a  preparatory 
condition.  The  brain  is  large,  but  contains  a  large  per- 
centage of  water,  is  soft,  and  its  gray  and  white  sub- 
stances differ  but  little  in  color  and  composition.  The 
spinal  cord  has  not  yet  the  consistency  of  a  later  period; 
the  anterior  horns  are  predominant,  and  therefore  more 
frequently  the  seat  of  pathological  changes.  The  periph- 
eral nerves  are  relatively  large,  but  little  excitable,  in 
the  first  days.  Their  excitability  grows  very  fast,  however, 
towards  the  end  of  the  first  year,  and  quite  out  of  pro- 
portion with  the  slow  development  of  the  inhibitory  centers. 
Thus  it  is  that  about  that  time  convulsive  symptoms  are 
so  very  frequent.  For  a  short  time  after  birth  the  con- 
ducting fibres  between  the  undeveloped  brain  (it  takes 
the  psycho-motor  centers  of  Ferrier  and  Hitzig  a  month 
to  exhibit  the  first  signs  of  existence)  and  the  pyramidal 
fibres  of  the  cord  perform  no  functions ;  thus  the  first 
movements  of  the  newly-born  are  not  controlled  by  will- 
power at  all,  but  subject  to  reflex  exclusively.  After  that 
time  the  brain  develops  very  fast  indeed,  but  far  from 
uniformly  in  all  its  parts.  It  is  a  most  interesting  study 
thus  to  follow  the  evolution  of  the  cerebral  functions  in 
their  dependency  upon  the  anatomical  development. 

The  digestive  organs  of  the  infant  exhibit  a  great  many 
peculiarities  in  their  anatomy,  physiology,  and  pathology. 
The  epithelial  "  pearls  "  along  the  median  line  of  the 
palate,  and  the  thinness  of  the  mucous  membranes  over 
the  roof  of  the  oral  cavity  and  along  the  gums,  give  rise 
to  early  trouble,  the  small  size  and  vertical  position  of  the 
stomach  to  a  number  of  abnormal  symptoms,  the  con- 
genital malformations  of  the  intestine  to  serious  dangers, 
the  abnormal  length  of  the  lower  part  of  the  colon  to  an 
unusual  form  of  protracted  constipation,  the  prevalence 
of  polypi  in  the  rectum  to  hemorrhages  of  a  kind  seldom 
found  in  advanced  age.  The  glands  required  for  the  di- 
gestive   processes    are    but    gradually    prepared    for    their 

30 


INTRODUCTORY    CHAPTER 

functions.  The  salivary  glands  are  but  partially  active 
at  birth,  the  pancreas  requires  time  for  its  full  develop- 
ment, the  secretion  of  lactic  predominates  over  that  of 
muriatic  acid  in  the  stomach,  the  intestinal  lymph-bodies 
are  in  part,  particularly  the  patches  of  Peyer,  so  behind 
their  future  size  and  formation  as  to  change  their  func- 
tions considerably.  The  time  of  dentition  adds  to  the  in- 
terest of  the  period,  more,  it  is  true,  from  a  physiological 
and  anatomical  standpoint  than  on  account  of  patho- 
logical reasons;  for  its  alleged  causal  connection  with 
the  large  number  of  diseases  attributed  to  its  mere  occur- 
rence has  been  greatly  exaggerated. 

In  connection  with  these  brief  remarks  on  some  of  the 
peculiarities  of  the  alimentary  tract  of  infancy,  I  may  be 
permitted  to  merely  allude  to  the  question  of  nutrition  and 
feeding.  Several  meetings  of  the  Children's  Section  of  the 
German  Association  of  Physicians  and  Naturalists,  the  last 
one  of  that  in  the  American  Medical  Association,  and  the 
deliberations  of  every  medical  society  in  every  land,  prove 
its  importance.  These  questions  belong,  as  special  stud- 
ies, eminently  to  pediatrics ;  physiology  and  chemistry  can 
teach  the  general  principles  only,  and  to  clinical  observa- 
tion is  left  the  final  settlement  of  the  hygiene  of  infancy. 
The  relation  of  nurse's  to  mother's  milk,  the  utilization  of 
cow's  milk  in  all  its  different  forms  as  one  of  the  con- 
stituents of  artificial  foods,  the  value  of  farinaceous  ad- 
mixtures, the  addition  of  animal  foods,  the  proportions  of 
salts  and  water,  the  quantity  to  be  administered,  the 
length  of  intervals  between  meals,  the  alterations  required 
in  sickness,  are  just  so  many  questions  which  demand 
persistent  study  and  special  industry. 

The  blood  and  the  organs  of  circulation  exhibit  the  most 
interesting  differences  in  the  young  as  compared  with  the 
adult. 

The  young  infant  (and  child)  has  less  blood  in  propor- 
tion to  its  entire  weight;  this  blood  has  less  fibrin,  fewer 
salts,  less  hsemoglobulin  (except  in  the  newly-born),  less 
soluble  albumin,  less  specific  gravity,  and  more  white  blood- 
corpuscles  than  the  blood  of  advanced  age. 

There  are  some  other  differences,  depending  on  age,  in 

31 


DR.    JACOBFS    WORKS 

the  composition  of  the  blood,  more  or  less  essential.  The 
foetal  blood  and  that  of  the  newborn  contain  but  little 
fibrin,  but  vigorous  respiration  works  great  changes  in  that 
respect.  Nasse  found  the  blood  of  young  animals  to  co- 
agulate but  slowly.  In  accordance  with  that  observation, 
it  strikes  us,  in  regard  to  cerebral  apoplexy  of  the  new- 
born, that  the  time  for  coagulation  of  the  blood  must  be 
longer  than  in  the  adult;  for  hemorrhages  are  apt  to  be 
most  extensive  in  the  infant.  In  the  sanguineous  tumor 
(kephalhaematoma)  of  the  newly-born,  the  blood  remains 
liquid  in  the  sac  for  many  days.  In  apoplexy  it  is  apt 
to  spread  all  over  the  hemispheres,  and  has  plenty  of 
time  to  perforate  and  penetrate  the  pia  in  all  directions, 
destroy  much  of  the  cerebral  tissue,  and  flow  down  the 
spinal  cavity.  These  occurrences  are  so  frequent  in  the 
infant,  and  so  rare  in  the  apoplectic  adult,  that  they  can 
hardly  be  explained  except  through  the  insufficient  co- 
agulability of  foetal  and  infant  blood. 

The  size  and  vigor  of  the  newly-born  heart  offer  a  ready 
explanation  of  the  rapid  growth  of  the  infant  body,  and 
mainly  those  organs  which  are  in  the  most  direct  com- 
munication with  the  heart  by  straight  and  fairly  large 
blood-vessels.  In  this  condition  are  the  head  and  brain. 
Thus  the  latter  has  an  opportunity  to  grow  from  400 
grammes  to  800  in  one  year;  after  that  period  its  growth 
becomes  less  marked.  At  seven,  boys  have  brains  of 
1,100  grammes;  girls,  of  1,000.  In  more  advanced  life 
its  weight  is  relatively  less, — 1,424  in  the  male  and  1,272 
in  the  female.  At  the  same  early  period  the  whole  body 
grows  in  both  length  and  weight.  The  original  length  of 
50  centimeters  of  the  newly-born  increases  to  110  with 
the  seventh  year;  the  greatest  increase  after  that  time 
amounts  to  60  (in  the  female  50)  centimeters  only.  In 
the  same  time  the  weight  increases  from  3.2  kilogrammes 
to  20.16  in  the  boy,  from  2.9  to  18.45  in  the  girl.  This 
gives  a  proportion  of  1  to  6  or  7,  while  after  that  time 
the  increase  is  but  three-  or  fourfold. 

The  normal  relation  of  the  weight  of  the  heart  to  that 
of  the  lungs,  between  the  second  and  twentieth  year,  is 
1:5-7;  in  scrofula  it  is   1:8-10.     That  means,  the  heart 

32 


INTRODUCTORY  CHAPTER 

is  smaller  than  normal,  in  the  latter  condition.  Other  parts 
of  the  system  of  circulation  exhibit  traits  of  their  own. 
It  is  particularly  in  the  "  torpid  "  form  of  scrofula  that, 
by  virtue  of  insufficient  circulation,  the  lymphatic  system 
participates  pre-eminently.  This  fact  is  the  more  impor- 
tant, as  the  size,  patency,  and  number  of  lymphatics  are 
quite  unusual  in  infancy.  Sappey  found  that  they  could 
be  more  easily  injected  in  the  child  than  in  the  adult, 
and  the  intercommunication  between  them  and  the  general 
system  is  more  marked  at  that  than  at  any  other  period 
of  life.  These  facts  have  been  confirmed  by  S.  L.  Schenk, 
who,  moreover,  found  the  net-work  of  the  lymphatics  even 
in  the  skin  of  the  newly-born  endowed  with  open  stomata, 
through  which  the  lymph-ducts  can  communicate  with  the 
neighboring  tissue  and  cells. 

In  rhachitis,  the  heart  is  of  average  size,  but  the  arteries 
are  abnormally  large.  Great  width  of  the  arteries  lowers 
blood-pressure.  This  allows  of  the  best  explanation  of  the 
murmur  first  discovered  by  Fisher,  of  Boston,  over  the  open 
fontanelles  of  rhachitical  babies,  a  very  much  better  one 
than  that  proposed  by  Jurasz,  who  looks  for  their  cause 
in  irregularities  of  the  canalis  caroticus.  Still,  it  is  a 
mistake  to  believe  that  these  murmurs,  audible  over  the 
brain,  belong  to  rhachitis  only.  They  are  found  in  every 
condition  in  which  the  blood-pressure  in  the  large  arteries 
of  the  cranial  cavity  is  lessened. 

E.  Hoffmann  discovered  the  peculiar  fact  that  the  ar- 
terial pressure  is  very  small  in  the  newly-born  animal. 
Even  as  large  arteries  as  the  carotid,  when  cut,  do  not 
spurt  as  in  the  adult.  This  low  arterial  pressure  is  one 
of  the  reasons  why  cords  not  ligated  will  often  not  bleed, 
with  the  exception  of  those  cases  in  which  the  arterial 
pressure  is  increased  by  a  moderate  degree  of  asphyxia, 
or  when  the  lungs  are  not  inflated  in  consequence  of  in- 
complete development  of  the  muscular  strength  in  the  pre- 
maturely-born foetus. 

According  to  a  number  of  actual  observations  made  by 
R.  Thoma,  the  post-foetal  growth  is  relatively  smallest  in 
the  common  carotid,  and  largest  in  the  renal  and  fem- 
oral  arteries.      Between     these     two     extremes     there    are 

33 


DR.    JACOBI'S    WORKS 

found  the  subclavian,  aortic,  and  pulmonary  arteries.  These 
are  differences  which  correspond  with  the  differences  in 
the  growth  of  the  several  parts  of  the  body  supplied  by 
those  blood-vessels.  In  regard  to  the  renal  artery  and  the 
kidney,  it  has  been  found  that  the  size  of  the  former  in- 
creases more  rapidly  than  the  volume  and  weight  of  the 
latter.  Thus  it  ought  to  be  expected  that  the  frequency  of 
congestive  and  inflammatory  processes  in  the  renal  tissue 
will  be  almost  predestined  by  the  disproportion  between 
the  size  of  the  artery  and  the  condition  of  the  tissue.  More- 
over, the  resistance  of  the  arterial  current  offered  bj'  the 
kidney-substance  depends  also  upon  the  readiness  with 
which  the  current  is  permitted  to  pass  the  capillaries. 
Now,  it  has  been  found  experimentally  that  their  per- 
meability is  greater,  and  that  within  a  given  time  more 
water  proportionately  can  be  squeezed  through  them,  in 
the  adult,  than  in  the  child.  This  anatomical  difference 
may  therefore  be  the  reason  why  renal  diseases  are  so 
much  more  frequent  in  infancy  and  childhood  from  all 
causes,  with  the  exception  of  that  one  which  is  reserved 
for  the  last  decades  of  natural  life,  viz.,  atheromatous  de- 
generation. 

In  the  arteries  of  medium  and  small  calibre  the  elastic 
membrane  is  a  thin  and  simple  membrane;  it  is  only  in 
larger  arteries  that  elastic  fibres  will  also  extend  into,  and 
mix  with,  the  adjoining  layers.  The  elastic  membrane  is 
particularly  thin,  may  even  be  entirely  absent,  where 
the  branches  are  given  off  from  the  arteries.  It  is  here 
that  spontaneous  hemorrhages  are  most  apt  to  take  place. 
It  is  here  also  that,  in  later  life,  aneurisms  are  met  with, 
such  as  find  no  ready  explanation  by  an  injury. 

The  anatomical  structure  of  the  three  umbilical  vessels 
differs  from  that  of  all  the  rest  of  either  arteries  or  veins 
in  many  points,  principally  in  this,  that  there  is  no  elastic 
membrane  and  no  intima  in  the  arteries.  Some  elastic 
tissue  is  found  near  the  umbilicus,  and  it  gradually  in- 
creases in  the  abdominal  cavity;  but  the  intima  is  not  de- 
veloped in  the  arteries  until  they  are  in  close  proximity 
to  the  iliac.  Thus  by  the  massive  and  powerful  develop- 
ment of  the  muscular  layer  it  is  explained  why  there  are 

34 


INTRODUCTORY  CHAPTER 

so  few  hemorrhages  though  no  ligature  has  been  applied 
to  the  cord. 

The  umbilical  vein  differs  from  the  arteries  very  much 
less  than  is  usual  with  veins  and  arteries  in  any  other 
parts  of  the  body.  The  muscular  layer  is  very  large  and 
strong  in  the  vein.  There  is  no  intima.  None  of  the  three 
vessels  emits  branches;  there  are  no  vasa  vasorum  and  no 
nerves   in  their   walls. 

Altogether,  the  growth  of  the  internal  organs  and  the 
whole  body  does  not  proceed  uniformly.  In  this  respect 
the  blood-vessels  do  not  stand  alone.  What  Beneke  called 
the  morbid  disposition  of  the  several  ages,  is  best  ex- 
plained by  these  variations  in  growth  and  power.  That 
author  spent  much  time  and  labor  on  the  measuring  of 
blood-vessels  in  particular.  It  was  he  that  found  the  ar- 
teries proportionately  wide  until  the  period  of  puberty. 
From  that  time  the  heart  increases  rapidly,  and  the  ar- 
teries less.  In  infancy  the  relation  of  the  volume  of  the 
heart  to  the  width  of  the  ascending  aorta  is  25 :  20,  before 
puberty  140:56,  and  after  puberty  290:61.  Thus  it  is 
that  the  general  arterial  blood-pressure  of  infants  is  less 
and  the  heart-beats  are  more  frequent. 

After  birth  the  pulmonary  artery  is  much  larger  than 
the  aorta;  after  the  first  year  the  width  of  the  former 
compared  with  that  of  the  latter  is  46 :  40,  in  the  adult 
35.9:36.2,  in  advanced  age  38.2:40.4.  It  is  easily  under- 
stood to  what  extent  both  the  normal  development  and  the 
diseases  of  the  lungs  may  be  influenced  by  these  relative 
sizes  of  the  vessels.  That  the  size  and  strength  of  the 
right  heart  should  have  a  favorable  influence  on  the  course 
of  a  pneumonia  is  an  inference  deserving  of  credit. 

The  reverse  of  the  normal  oversize  of  blood-vessels  in 
the  infant  and  child  is  found  in  abnormal  smallness,  par- 
ticularly of  the  arteries.  The  worst,  and  mostly  incurable, 
forms  of  chlorosis  are  the  results  of  this  anomaly.  They 
have  been  studied  by  Trousseau,  Virchow,  See,  and  others, 
in  connection  with  a  small,  or  normal,  or  fatty  heart,  and 
in  their  complications  with  occasional  hemorrhagic  dia- 
thesis. All  forms  of  persistent  anaemia  may  depend  on 
this  insufficient  development  of  the  arteries:  the  specimens 

35 


DR.    JACOBI'S    WORKS 

taken  from  a  woman  of  thirty-two  years,  who  died  with  all 
the  symptoms  of  "  essential "  anaemia,  are  in  my  pos- 
session. 

To  the  consideration  of  the  organs  of  circulation  I  have 
given  so  much  prominence  because  of  their  pre-eminent 
influence  in  etiology.  The  changes  of  periods  of  life 
and  advancing  age  are  mainly  occasioned  by  the  altera- 
tions in  the  structure  of  the  walls  of  the  blood-vessels. 
Their  original  thinness  and  fragility  occasion  hemorrhages 
in  the  newly-born,  as  does  their  anomalous  condition  in 
senility.  Nor  is  there  any  organ  which  is  not  constantly 
under  the  control  of  the  blood-current.  This  chapter 
would,  however,  grow  to  undue  length,  and  encroach  too 
much  upon  the  legitimate  province  of  the  special  essays 
devoted  to  the  consideration  of  the  subjects  to  which  I 
should  only  allude,  were  I  to  continue  to  enlarge  upon 
them.     A  few  more  remarks,  therefore,  may  suffice. 

There  are  anomalies  and  diseases  which  are  met  with  in 
the  infant  and  child  only.  Among  this  class  we  meet  con- 
genital diseases  and  malformations,  the  aff"ections  of  the 
umbilical  cord,  of  the  ductus  arteriosus,  and  of  the  tunica 
vaginalis  of  the  spermatic  cord,  atelectasis  and  cyanosis, 
the  diseases  of  the  thymus,  the  anomalies  of  the  intestinal 
tract,  congenital  constipation,  as  I  have  called  it,  result- 
ing from  the  exaggeration  of  the  normal  length  of  the 
long  sigmoid  flexure,  and,  finally,  rhachitis. 

Other  diseases  are  mostly  found  in  children,  or  with  a 
characteristic  symptomatology  and  course.  Both  acute  and 
chronic  hydrocephalus,  acute  eruptive  diseases,  whooping- 
cough,  and  diphtheria  are  mostly  found  at  an  early  age. 
Diphtheria  is  very  liable  to  assume  diff"erent  characters 
in  diff"erent  ages;  even  the  simple  inflammations  of  the 
tonsils  vary  in  severity  and  nature  according  to  the  amount 
of  tissue  destroyed  or  new  hyperplastic  connective  tissue 
formed  in  the  course  of  repeated  attacks.  Almost  all  the 
diseases  of  the  intestinal  tract  in  children  have  their  pe- 
culiarities, and  require  the  special  study  of  foods  and  hy- 
giene. The  majority  of  cases  of  intussusception  take  place 
in  infants,  in  localities  with  symptoms  of  their  own. 

There  are  diseases  which  affect  both  the  young  and  the 

86 


INTRODUCTORY    CHAPTER 

old;  in  them  the  size  or  nature  of  the  organ,  or  the 
difference  in  the  degree  of  irritatibility,  affect  the  sympto- 
matology of  the  case  considerably.  In  the  narrow  larynx 
of  the  child,  diphtheria  gives  rise  to  the  complex  symp- 
toms of  pseudo-membranous  croup.  Tracheotomy  and  in- 
tubation are  subjects  eminently  belonging  to  pediatrics.  In 
the  vulnerable  infant  only,  intestinal  worms  will  give  rise 
to  convulsions;  and  the  large  majority  of  cases  of  polio- 
myelitis and  polioencephalitis  also  are  reserved  for  infancy; 
indeed,  so  great  is  the  difference  between  the  ages,  that 
the  infant  is  the  proprietor  of  the  medio-canellata,  while 
the  adult  glories  in  the  taenia  solium  as  a  tenant.  Let  me 
add  that  there  are  differences  of  many  degrees  in  many 
other  diseases,  accordingly  as  they  occur  in  the  young 
or  in  the  old.  The  pneumonia,  tuberculosis,  typhoid  fever, 
rheumatism,  epilepsy,  and  diabetes  of  the  young  differ 
considerably  from  the  same  affections  of  the  adult,  in 
their  clinical  and,  sometimes,  anatomical  aspects. 

Therapeutics  of  infancy  and  childhood  are  by  no  means 
so  similar  to  those  of  the  adult  that  the  rules  of  the  latter 
can  simply  be  adopted  to  the  former  by  reducing  doses. 
The  differences  are  many.  Among  the  antifebriles  cold 
is  tolerated  less,  quinine  more,  in  proportion,  than  in  the 
adult.  So  are  antipyrin  and  antifebrin,  also  phenacetin. 
Heart-stimidants  are  also  borne  in  relatively  large  doses: 
thus,  digitalis,  strophanthus,  and  sparteine.  Caffeine  is 
less  advisable  except  where  there  is  positively  no  cerebral 
complication  of  a  congestive  or  inflammatory  nature.  Of 
the  narcotics,  opium  must  be  watched;  its  doses  must  be 
relatively  small.  Belladonna  is  borne  in  rather  large  doses, 
and  hyoscyamus  can  be  given  in  much  larger  doses  pro- 
portionately in  spasmodic  conditions  of  the  bladder  than 
in  advanced  age.  Some  of  the  powerful  medicines  are 
required  in  smaller,  some  in  larger  doses.  Chlorate  of 
potassium  demands  great  care ;  carbolic  acid  becomes  poi- 
sonous in  small  doses  given  to  the  very  young,  even  ex- 
ternally; preparations  of  arsenic  are  borne  in  rather  larger 
doses  for  many  weeks  and  months;  corrosive  sublimate — 
mercurials  generally — in  rather  large  doses,  because  of 
the  extraordinary  immunity  in  regard  to  stomatitis  and  to 

37 


DR.    JACOBI'S    WORKS 

the  gastric  and  intestinal  irritation  so  often  observed  in 
the  adult. 

Now,  what  has  been  done  to  facilitate  the  acquisition  of 
knowledge  on  all  these  points  by  the  student  and  prac- 
titioner of  medicine.''  Very  little  indeed.  There  never 
was  any  systematic  instruction  in  the  diseases  of  children, 
by  a  teacher  appointed  for  that  branch  of  medicine  ex- 
clusively, until  (in  I860)  I  established  a  weekly  children's 
clinic  in  the  New  York  Medical  College,  at  that  time  in 
East  Thirteenth  Street.  That  was  the  first  of  its  kind 
in  the  United  States.  When  the  college  ceased  to  exist 
(in  1865)  I  established  a  children's  clinic  in  the  Uni- 
versity Medical  College  and  in  1870  in  the  College  of  Phy- 
sicians and  Surgeons.  In  both  these  institutions,  as  also 
in  the  Bellevue  Hospital  Medical  College,  such  clinics 
have  existed  since,  and  a  number  of  the  medical  schools 
of  the  country  have  imitated  the  example. 

In  them,  a  single  hour  weekly,  during  the  regular  courses 
of  the  winter,  is  given  to  the  student  of  medicine  for  the 
special  study  of  the  diseases  of  children,  who  will,  in  his 
future  practice,  form  the  majority  of  his  patients.  In  the 
course  of  four  so-called  years,  which  the  legislatures  of 
our  States  pronounce  sufficient  for  the  attainment  of  all 
medical  knowledge  required  for  the  welfare  of  the  coun- 
try, the  student  is  pressed  very  hard  for  time.  There 
are  a  number  of  branches  which  he  is  taught  to  deem 
worth  his  while  and  attention,  by  being  told  that  he  will 
be  examined  in  them  before  obtaining  his  diploma ;  but 
the  diseases  of  children  are  not  now  among  these.  To  my 
knowledge,  there  is  no  school  in  the  country  which  lays 
the  least  stress  on  that  branch  of  instruction;  for  I  hope 
there  is  nobody  nowadays,  even  among  the  teachers  of  medi- 
cine, who  believes  that  a  few  didactic  lectures  of  the  pro- 
fessor of  "  theory  and  practice  "  are  a  sufficient  prepara- 
tion for  the  preservation  of  the  children  of  the  people. 
No  examination  being  required  by  those  to  whom  the  stu- 
dent looks  for  direction  and  enlightenment,  he  neglects 
the  study,  to  find  out  too  late  the  mistake  he  has  made  in 
so  doing. 

It  is  no  consolation  that  in  Great  Britain  the  same  com- 

88 


INTRODUCTORY    CHAPTER 

plaints  are  made.  But  a  few  months  ago  the  chairman  of 
the  Section  of  Diseases  of  Children,  Dr.  Cheadle,  spoke 
in  feeling  terms  of  the  neglect  in  the  schools  and  clinical 
institutions  of  Great  Britain  of  this  most  important  part 
of  practical  medicine,  before  the  British  Medical  Asso- 
ciation. The  continent  of  Europe  has  made  more  rapid 
progress.  Most  of  both  the  large  and  the  small  univer- 
sities have  their  chair  of  the  Diseases  of  Children,  not  a 
"  clinical "  one,  which  means  the  authority  given  an  en- 
thusiastic worker  to  teach  as  much  or  as  little  as  he  can  in 
an  hour  weekly,  without  recognition,  thanks,  or  reward, 
of  a  doctrine  not  officially  recognized;  they  have  hospitals 
in  which  to  teach  practically  every  day  what  has  been 
taught  in  didactic  lectures  and  learned  from  books,  and 
their  students  know  beforehand  that  they  will  have  to 
prove,  before  being  permitted  to  practise,  their  acquaint- 
ance with  what  they  are  compelled  to  learn  of  the  diseases 
of  children.  Thus  it  is  in  France  and  Italy,  in  Germany, 
Austria,  and  Sweden ;  thus  it  is  now  in  Russia,  but  not 
so  in  England  and  in  our  coimtry. 

What  can  be   done  to  improve  this  state  of  things? 

Every  future  improvement  in  general  medical  education 
will  favor  the  study  of  pediatrics.  There  will  be  a  time 
in  the  near  future  when  the  student  in  medicine  will  be 
aware  that  he  will  have  to  pass  an  examination  in  the  sub- 
jects connected  with  the  physiology  and  pathology  of  the 
young.  There  will  be  another  time  when  the  medical 
courses  will  be  both  long  and  numerous  enough  to  permit 
of  clinical  instruction  in  the  diseases  of  children  being 
given  three  or  six  times  a  week,  and  another  in  which  there 
will  be  bedside  teaching.  For  that  purpose  it  is  that 
either  special  hospitals  or  large  wards  in  general  hos- 
pitals are  an  absolute  necessity.  It  is  in  them  only  that 
the  student,  and  the  professional  man  also,  may  learn  under 
supervision,  and  without  the  danger  of  each  having  to 
fill  with  victims  a  burying-ground  of  his  own,  both  how 
to  diagnosticate  a  disease  in  a  child  and  how  to  nurse 
and  treat  a  sick  one.  In  hospitals  alone  can  good  ob- 
servations be  made  in  reference  to  the  course  of  diseases, 
and  the  effects  of  remedies  and  methods  of  treatment. 

39 


DR.    JACOBI'S    WORKS 

Moreover^  special  societies  must  be  founded  for  the  pur- 
pose of  studying  questions  connected  with  pediatrics,  or 
special  sections  formed  in  larger  and  established  asso- 
ciations. The  new  Children's  Section  in  the  New  York 
Academy  of  Medicine,  that  of  the  American  Medical  As- 
sociation, and  the  successful  organization  of  the  American 
Pediatric  Society  prove  the  intensity  of  the  interest  the 
American  profession  has  commenced  to  take  in  the  sub- 
jects legitimately  belonging  to  that  part  of  medical  science 
and  practice. 

Finally,  all  of  the  latter,  as  well  as  those  to  which  I  could 
but  incompletely  allude,  as  all  others  suggesting  them- 
selves to  the  careful  observer  and  thorough  student,  must 
be  the  themes  of  persistent  individual  study.  Besides, 
as  there  must  be  time  to  learn  other  men's  observations, 
so  time  must  be  found  to  contribute  what  is  new  and  val- 
uable in  every  professional  man's  life.  The  basis  on 
which  to  proceed  is  to  be  furnished  by  this  Cyclopaedia, 
the  introductory  remarks  to  which  I  am  kindly  permitted 
to  offer.  This  book  bids  fair  to  contain  all  that  is  known 
at  present  on  the  anatomy,  physiology,  pathology,  and 
therapeutics  of  infancy  and  childhood.  May  the  American 
profession  see  to  it  that  this  same  book,  while  being  a 
digest  both  of  the  labors  of  the  past  and  the  attainments 
of  the  present,  shall  become  the  solid  foundation  of  suc- 
cessful scientific  work  in  both  the  near  and  distant  future. 


40 


THE  RELATIONS  OF  PEDIATRICS  TO 
GENERAL  MEDICINE 

Gentlemen: — Progress  and  success,  in  order  to  be  com- 
plete and  unmistakable,  require  centralization  of  means  and 
co-operation  of  men.  The  pioneer  in  his  seclusion,  the 
hard-working  settlement,  the  thin  population  of  a  county, 
the  joining  of  the  disseminated  parts  to  form  a  state,  and 
the  amalgamation  resulting  in  the  establishment  of  a 
powerful  and  world-moving  nationality,  exhibit  an  example 
of  the  geometrical  increase  of  strength  resulting  from  the 
combination  of  forces.  The  isolated  labors  of  the  greatest 
men  in  the  history  of  science  never  accomplished  anything 
beyond  a  spasmodic  and  stationary  advance.  Twenty  cen- 
turies in  succession  lived  on  the  unchanged  teachings  of 
Hippocrates,  Aristotle,  and  Galen. 

The  establishment  of  institutions  of  learning  in  modern 
times,  mainly  since  the  fifteenth  and  sixteenth  centuries, 
multiplied  the  names  of  men,  though  none  reached  those 
three  ancients,  who,  in  contact  with  others  equally  dis- 
posed, labored  successfully  in  the  interests  of  science. 
Paracelsus,  Descartes,  Sydenham,  Boerhaave,  Van- 
Swieten,  Haller,  Pete  Frank,  and  Bichat  promoted  science, 
partly  through  contest,  partly  through  co-operation  with 
fellow-laborers.  The  multiplication  of  institutions,  the 
similarity  of  aims  and  ambitions,  the  establishment  of 
faculties  and  learned  societies,  accomplished,  through  the 
co-operation  and  friction  thus  created,  a  progress  more 
pronounced  in  decades  than  formerly  in  centuries. 

The  best  results,  however,  were  obtained  by  the  volun- 
tary association  of  scientific  men  all  over  the  world.  In 
this  century,  the  German  Association  of  Naturalists  and 
Physicians,  the  British  and  the  American  Medical  Asso- 
ciation, the  numerous  local  and  provincial  societies,  and  last, 
though  by  far  not  least,  the  American  Congress  of  Physi- 

41 


DR.    JACOBI'S    WORKS 

cians  and  Surgeons,  with  its  many  special  associations  and 
societies,  have  not  only  encouraged  scientific  originality, 
but  raised  the  average  standard  of  the  profession  at  large. 

That  is  what  the  isolated  labors  of  individual  men  never 
attained.  From  this  point  of  view  I  hailed  the  proposal  to 
form  an  American  Pediatric  Society  with  satisfaction  and 
delight.  Thirty  years  ago  I  contemplated  the  formation  of  a 
section  for  the  purpose  of  studying  the  diseases  of  children 
in  the  New  York  Academy  of  Medicine,  and  failed.  These 
nine  years  the  American  Medical  Association  had  its  sec- 
tion on  diseases  of  children,  the  first  meeting  of  which 
took  place  under  the  presidency  of  S.  C.  Busey,  and  the 
New  York  Academy  of  Medicine  has  a  flourishing  pediatric 
section  under  J.  L.  Smith.  To-day  this  national  association 
has  convened  without  difficulties  and  with  all  the  promises 
of  speedy  success.  The  spontaneity  of  its  origin  is  a 
guarantee  of  vitality  and  prosperity.  My  failure  at  that 
early  time  did  not  signify  that  no  attention  had  been  paid 
in  the  United  States  to  the  phj'^siology  and  pathology  of 
infancy  and  childhood.  It  simply  meant  that  the  relations 
of  pediatrics  to  practice  and  to  the  other  departments  of 
medicine  were  not  yet  duly  appreciated.  In  most  countries 
in  Europe  it  was  the  same.  In  America  the  names  of 
Dewees,  Stewart,  Eberle,  Condie,  Charles  D.  Meigs,  John 
Forsyth  Meigs,  and  W.  V.  Keating  are  still  holding  an 
honorable  place  in  the  history  of  pediatrics.  But  their 
labors  were  individual  and  isolated.  Though  their  teach- 
ings were  appreciated,  the  profession  at  large  was  not 
sufficiently  advanced  to  look  upon  the  close  and  special 
study  of  the  diseases  of  children  as  a  necessity  from  the 
twofold  point  of  view  under  which  I  began  early  to  con- 
sider it.  I  was  ever  of  opinion  that  not  only  had  special 
occupation  with  infant  pathology  and  therapeutics  its  re- 
ward in  itself,  but  its  connection  with  every  other  special 
doctrine  aided  and  fostered  the  intimate  and  profound 
knowledge  of  other  branches  of  medical  science  and  art. 
Thus  the  future  connection  of  this  society  with  the  Trien- 
nial Congress  of  American  Physicians  and  Surgeons  will 
prove  a  mutual  benefit  to  all  parties  concerned. 

In  an  introductory  to  the  "  Cyclopaedia  of  the  Diseases 
42 


PEDIATRICS    AND    GENERAL    MEDICINE 

of  Children,"  edited  by  John  M.  Keating,  I  have  tried  to 
establish  the  claim  of  pediatrics  to  be  considered  a  spe- 
cialty. Not  that  it  is  one  in  the  common  acceptation  of  the 
term.  It  does  not  deal  with  a  special  organ,  but  with 
the  entire  organism  at  the  very  period  which  presents  the 
most  interesting  features  to  the  student  of  biology  and 
medicine.  Infancy  and  childhood  are  the  links  between 
conception  and  death,  between  the  foetus  and  the  adult. 
The  latter  has  attained  a  certain  degree  of  invariability. 
His  physiological  labor  is  reproduction ;  that  of  the  young 
is  both  reproduction  and  growth.  As  the  history  of  a  people 
is  not  complete  with  the  narration  of  its  condition  when 
established  on  a  solid  constitutional  and  economic  basis,  so 
is  that  of  man,  whether  healthy  or  diseased,  not  limited  to 
one  period.  Indeed,  the  most  interesting  time,  and  the  one 
most  difficult  to  understand,  is  that  in  which  persistent 
development,  increase,  solidification,  and  improvement  are 
taking  place. 

I  have  tried  to  prove  that  "  pediatrics  does  not  deal 
with  miniature  men  and  women,  with  reduced  doses  and 
the  same  class  of  diseases  in  smaller  bodies,  but  that  it  has 
its  own  independent  range  and  horizon,  and  gives  as  much 
to  general  medicine  as  it  has  received  from  it."  My  rea- 
soning was  that  there  is  scarcely  a  tissue  or  an  organ  which 
behaves  exactly  alike  in  the  different  periods  of  life.  I 
tried  to  prove  that  assertion  by  a  cursory  consideration  of 
the  osseous  tissue,  the  nervous  system,  the  digestive  organs, 
the  blood  and  the  system  of  circulation,  and  the  require- 
ments of  general  therapeutics  in  the  young.  To  these  ex- 
positions I  added  a  few  remarks  on  the  peculiar  character 
of  the  diseases  of  infancy  and  childhood.  There  are  anom- 
alies and  diseases  which  are  encountered  in  the  infant 
and  child  only.  There  are  those. which  are  mostly  found 
in  children,  or  with  a  symptomatology  and  course  peculiar 
to  them;  and  those,  finally,  which  affect  both  the  young 
and  old,  with  such  varieties,  however,  both  in  symptoms 
and  course,  as  depend  on  the  size  or  nature  of  the  afflicted 
organ  or  organism,  or  the  difference  in  the  degree  of  its 
irritability. 

The  relations  of  pediatrics  to  the  several  special  parts 

43 


t)ii.  JAcoBi's  wokkg 

of  the  extensive  field  of  scientific  medicine  are  very  various. 
Internal  medicine  owes  many  of  its  best  results  to  the  ob- 
servations made  on  infants  and  children.  It  is  in  them  that 
constitutional  and  developmental  diseases  are  either  best  or 
exclusively  studied.  In  this  connection  I  remind  you  only 
of  scrofula,  rhachitis,  anaemia,  and  chlorosis.  Infectious 
diseases,  such  as  diphtheria,  scarlatina,  measles,  varicella, 
parotitis,  pertussis,  and  tuberculosis,  mainly  of  the  bones 
and  joints,  of  the  glands  and  peritoneum,  are  mostly  en- 
countered in  infancy  and  childhood.  Neoplasms  are  not 
only  frequent  in  young  children, — more  than  forty  cases 
of  sarcoma  of  the  foetal  or  infant  kidney  alone  were  col- 
lected by  me  for  the  International  Congress  of  Copen- 
hagen five  years  ago, — but  rouse  the  most  intense  interest, 
from  the  fact  that  Cohnheim  tried  to  trace  every  neoplasm 
of  later  life  to  its  embryonic  or  foetal  origin.  All  the 
actual  or  alleged  disorders  belonging  to  dentition,  most 
forms  of  stomatitis,  amygdalitis,  and  pharyngitis,  includ- 
ing latero-  and  retro-pharyngeal  abscess,  many  of  the  most 
frequent  and  important  diseases  of  the  nose  with  their  con- 
sequences, and  of  the  larynx,  are  met  with  in  the  young.  It 
is  in  them  that  catarrhal  pneumonia  has  been  studied  prin- 
cipally, atelectasis  almost  exclusively.  Some  of  the  forms  of 
diarrhoea,  and  still  more  of  constipation,  are  exclusively  the 
property  of  young  children.  It  is  in  them,  also,  that  inter- 
nal medicine  has  learned  the  pathology  of  muscular  pseudo- 
hypertrophy; from  them,  finally,  that  it  has  improved  and 
increased  diagnostic  resources,  for  nobody  can  study  Fin- 
layson's  contribution  to  the  first  volume  of  the  Cyclopaedia 
without  finding  many  of  them  greatly  depending  on  certain 
peculiarities  of  the  several  infant  organs. 

The  surgery  of  infancy  and  childhood  is  so  peculiar,  its 
indications  so  varying,  the  number  of  cases  so  large,  and 
some  of  the  operative  procedures  so  exclusively  or  almost 
exclusively  adapted  to,  or  necessitated  by,  surgical  diseases 
of  the  young,  that  the  transactions  of  surgical  societies  and 
journals  are  largely  filled  with  discussions  on  subjects  be- 
longing to  the  sphere  of  pediatrics.  I  remind  you  of  the 
frequent  occurrence  of  congenital  malformations  requiring 
interference;  those  of  the  anus  and  rectum,  hare-lip  and 

44 


PEDIATRICS    AND    GENERAL    MEDICINE 

fissured  palate,  spina  bifida  and  hydrocephalus.  The  sev- 
eral forms  of  bone-disease,  in  the  vertebrae,  the  hip-  and 
ankle-joints  which  require  resection  or  scooping,  demand 
special  knowledge  and  skill,  because  of  the  dignity  of  the 
intermediate  cartilage.  Osteotomy  is  more  frequently  per- 
formed in  the  rickety  young  than  at  any  other  age  or  in 
any  other  disease.  Tubercular  swelling  of  the  lymph-bodies 
occurs  more  frequently  in  the  young  than  in  advanced  years. 
The  majority  of  tenotomies  are  performed  on  children. 
Tracheotomy  and  intubation  belong  pre-eminently  to  early 
age.  The  largest  number  of  tracheotomies  performed  by  an 
individual  operator  is  furnished  by  an  author  who  does  not 
claim  any  merit  as  a  professional  surgeon.  The  operation 
for  pyothorax  is  mostly  required  in  the  young,  and  taxes 
the  experience  and  prognostic  judgment  of  the  medical  man 
to  an  unusual  degree,  because  of  the  variety  of  indications 
depending  upon  the  amount  of  flexibility  of  the  ribs  and 
the  extent  of  complications.  Invagination  is  mainly  seen 
in  the  very  young.  Twenty-five  per  cent,  of  all  the  cases 
occur  under  one  year;  fifty-three  under  ten.  Two-thirds  of 
those  under  a  year  are  between  the  fourth  and  sixth  months. 
Perityphlitis,  though  rare  in  infants,  is  not  at  all  infre- 
quent in  children  of  seven  or  eight  years  and  upward ;  and 
both  it  and  intussusception  require  often  surgical  inter- 
ference. Indeed,  so  common  are  the  claims  on  surgical 
skill  in  the  practice  among  infants  and  children,  that  among 
the  most  instructive  and  interesting  surgical  treatises  are 
those  which  discuss  the  surgery  of  childhood  alone.  I  will 
only  recall  the  special  works  of  Guersant,  Forster,  Bryant, 
Giraldes,  Holmes,  St.  Germain,  and  the  fifteen  hundred 
pages  written  by  a  dozen  different  authors  in  C.  Gerhardt's 
"  Manual  of  the  Diseases  of  Children."  It  is  a  good  move 
on  the  part  of  the  editors  of  the  new  treatise  of  Henry 
Ashby  and  G.  A.  Wright  that  one  of  the  authors  is  an  ex- 
perienced operating  surgeon. 

The  connection  of  pediatrics  with  neurology  is  very  in- 
timate indeed.  Many  of  the  most  interesting  neuro-phy- 
siological  data  have  been  secured  by  our  special  colleagues. 
Thus,  Soltmann's  researches  prove  that  in  the  new-born 
the  inhibitory  centres  of  the  cerebral  cortex  are  almost  not 

45 


DR.    JACOBFS    WORKS 

formed  at  all,  and  that  the  motor  and  sensitive  irritability 
increases  rapidly  about  the  fifth  and  sixth  months.  This  is 
the  time  at  which  reflex  excitability  is  very  great.  It  has 
also  been  found  that  the  inhibitory  function  of  the  cardiac 
nerves  is  but  feeble  in  the  very  young.  The  contraction  un- 
der the  influence  of  the  electric  current  resembles  very  much 
that  which  is  observed  in  the  fatigued  animal,  and  the 
peripheral  nerves  exhibit  a  slight  excitability  only.  Many 
other  observations  can  be  made  on  the  infant  only, — thus, 
for  instance,  those  concerning  the  first  awakening  of  per- 
ception. On  the  first  or  second  day  of  life  hearing  is  active ; 
sight  sufficiently  developed  to  be  afl^ected  by  light  and  dark- 
ness; taste  and  smell  exist,  but  are  feeble,  and  the  sense 
of  touch  is  mainly  demonstrable  on  the  lips.  The  percep- 
tion of  pain  is  but  slightly  developed. 

Many  such  special  contributions  to  the  physiology  of  the 
nervous  system  gathered  in  the  young  could  be  introduced 
here.  I  can  omit  that  in  the  presence  of  those  who  know; 
but  refer  to  the  special  works  of  Kussmaul,  G.  Darwin,  and 
Preyer,  which  treat  of  the  psychology  of  the  infant,  and  to 
the  general  treatises  on  the  physiology  of  the  young  by 
Alleix,   Vierordt,   and   Vittorio   Massini. 

Neuropathology  also  owes  a  great  many  results  to  the  ob- 
servations made  on  infants  and  children.  Disorders  of  the 
nervous  system  are  very  common  in  the  young.  Of  all  the 
deaths  resulting  from  diseases  of  the  nervous  system,  eighty- 
seven  per  cent,  take  place  during  the  first  five  years  of  life. 
Their  frequency  is  best  understood  by  the  consideration  of 
their  many  causes.  Many  are  inherited  or  acquired  during 
foetal  life.  Others  are  due  to  the  insufficiency  of  the  protec- 
tion aff"orded  to  the  brain.  Thus  it  is  that  any  trauma,  the 
pressure  of  a  narrow  pelvis  or  the  forceps,  a  fall  which  in 
the  very  young  produces  rather  a  general  disorder  than  a 
local  lesion,  leads  to  serious  consequences.  The  neighboring 
organs,  such  as  the  ear,  or  the  scalp,  are  liable  to  aff'ect  the 
brain;  for  that  reason  otitis  and  impetigo  are  dangerous 
processes.  The  very  anatomical  development,  the  increas- 
ing separation  of  the  two  cerebral  substances,  and  the  in- 
competency of  the  centres  of  inhibition  and  those  of  co- 
ordination,  lead  to   morbid   processes.     Anomalies  of  the 

46 


PEDIATRICS    AND    GENERAL    MEDICINE 

bones,  such  as  rhachitic  softening  and,  still  more,  premature 
ossification,  interfere  with  the  cerebral  development  or  lead 
directly  to  serious  or  incurable  alterations.  The  incom- 
plete structure  of  the  blood-vessels  is  another  frequent 
cause  of  disease  from  mere  temporary  congestion  to  serous 
effusions  or  to  extravasations.  Thus  we  have  an  expla- 
nation of  many  of  the  facts  unaccountable  to  the  super- 
ficial observer  only.  The  number  of  neuropathies  not  di- 
rectly fatal  is  excessive  in  the  young.  Convulsions  of  every 
description,  eclampsia,  chorea,  tetany,  epilepsy  (poliomy- 
elitis), Friedreich's  ataxia,  gather  their  most  copious  har- 
vest among  infants  and  children.  And  again  it  is  these 
on  whom  most  of  our  knowledge  of  cerebro-spinal  menin- 
gitis and  cerebral  meningitis   has  been  obtained. 

Neurology's  sister,  psychology,  is  indebted  for  much  of 
its  wealth  to  the  study  of  the  intellectual  life  of  infancy 
and  childhood.  It  is  sufficient  to  refer  again  to  the  valu- 
able and  influential  researches  of  Kussmaul,  the  younger 
Darwin,  and  W.  Preyer.  Psychiatry  also  has  learned  from 
the  mental  aberrations  occurring  at  an  early  age,  the  more 
so  as  many  of  the  causes  of  mental  disease  in  later  life 
must  be  traced  back  to  embryological  data  and  the  morbid 
changes  of  infancy.  Asphyxia  of  the  newly-born,  with  its 
resulting  effusion,  extravasations,  or  thromboses,  is  a  fre- 
quent cause  of  life-long  epilepsy,  stupidity,  or  idiocy. 
Diseases  affecting  the  brain  at  an  early  period  preclude 
the  formation  of  ideas.  The  absence  of  inhibitory  and 
psychomotor  centres  in  the  newly-born  animal  precludes 
the  equilibrium  required  for  a  normal  mental  organization. 
The  disposition  to  psychical  disturbance  resulting  from  in- 
dividual constitution,  the  influences  of  heredity,  and  con- 
genital neurasthenia  can  be  studied  at  the  very  earliest 
age.  The  symptoms  of  fully-developed  or  imminent  or 
future  mental  disease  are  more  readily  studied  in  the  young 
than  at  more  advanced  age,  for  in  the  young  the  slightest 
deviations  will  tell.  Such  symptoms,  which  are  easily  rec- 
ognized, are  waywardness  and  restlessness,  grimacing,  con- 
v^ulsive  twitching  and  convulsibility,  abnormal  sleep,  re- 
tardation of  growth,  and  excessive  masturbation.  Wher- 
ever they  are  found  to  be  not  the  direct  results  of  easily 

47 


DR.    JACOBI'S    WORKS 

appreciated  causes, — as,  for  instance,  what  I  have  perhaps 
wrongly  called  local  chorea  depending  on  chronic  naso- 
pharyngeal catarrh, — psychical  disturbances  may  well  be 
feared.  They  are  more  frequent  than  the  reports  of  lunatic 
asylums  would  appear  to  prove.  For  there  are  but  few 
insane  children  in  the  institutions,  for  obvious  reasons.  It 
is  only  those  cases  which  become  absolutely  unmanageable 
at  home  which  are  intrusted  to  an  asylum.  Thus  it  is  that 
we  can  obtain  more  accurate  statistics  of  idiocy  than  of  de- 
mentia of  early  years.  The  anatomical  symptoms  of  degen- 
eration, leading  sooner  or  later  to  mental  disorders,  are  stud- 
ied to  best  advantage  mostly  in  infants  and  children.  Of 
epilepsy,  which  mostly  starts  early,  it  is  not  necessary  to 
speak  here.  I  shall  only  allude  to  the  deformities  of  the 
cranium  due  to  general  or  local  premature  ossification  of 
the  cranial  bones  and  fontanelles,  to  the  peculiarities  of  the 
position  of  the  teeth  and  ears,  the  retraced  root  of  the  nose, 
the  asymmetry  of  the  head  and  face,  due  either  to  unilat- 
eral atrophy  or  hypertrophy,  and  the  shortened  base  of  the 
skull.  Besides,  there  is  the  excessive  number  of  cerebral 
diseases  manifest  at  a  time  when  the  increasing  growth  of 
the  organs  continues  to  add  to  the  acquired  lesions ;  also 
trauma  and  insolation.  Finally,  the  impressibility  of  the 
young  is  such  that  the  causes  of  mental  disturbance  in 
every  age — chorea,  hysteria,  epilepsy,  anomalies  of  the 
ears,  nose,  and  heart,  the  presence  of  helminthes,  the  parox- 
ysms of  malaria,  the  anatomical  results  of  typhoid  fever, 
rheumatism,  erysipelas,  and  pertussis,  and  the  nutritive  dis- 
orders resulting  from  anaemia,  chlorosis,  and  alcohol — -have 
very  much  more  serious  results  when  occurring  at  an  early 
age.  There  are  some  causes  leading  to  mental  disturbances 
which  are  certainly  more  common  in  the  young, — viz.,  imi- 
tation, fear,  fright,  masturbation,  and  the  protracted  mis- 
takes constantly  made  in  regard  to  training  and  education. 
The  over-worked  brains  of  our  school-children  have  been 
complained  of  in  this  connection  as  early  as  1801  by  Peter 
Frank,  and  will  yet  form  the  subject  of  a  few  more  re- 
marks. 

The  history  of  the  embryo  and  foetus  finds  its  legitimate 
termination  in  that  of  the  infant  and  child.     Thus  embry- 

48 


PEDIATRICS    AND    GENERAL    MEDICINE 

ology,  teratology,  and  pedology,  with  pediatrics,  are  but 
chapters  of  the  same  book.  The  scientific  consideration  of 
any  one  of  them  is  impossible  without  that  of  the  others. 
The  theories  of  heredity  and  consanguinity  refer  equally  to 
all.  The  most  important  changes  and  diseases  met  with  in 
the  young  human  being  cannot  be  studied  without  the 
knowledge  of  its  previous  history,  and  the  intelligent  ap- 
preciation of  embryology  cannot  be  attained  without  the 
exact  knowledge  of  its  final  outcome.  Excessive  or  de- 
fective growth,  arrest  of  development,  and  foetal  inflam- 
mation are  the  heads  under  which  a  large  number  of 
anomalies  of  the  infant  can  be  classified.  The  frequent 
occurrence  of  carcinoma,  sarcoma,  and  lipoma  in  the  young 
favors  Cohnheim's  theory,  according  to  which  those  neo- 
plasms owe  their  origin  to  the  persistence  of  embryonic 
tissue.  Abnormally  inverted  circulation  explains  the  acar- 
diac  monstrosity;  deficiency  of  building  material  accounts 
for  the  absence  in  many  cases  of  limbs  or  parts  of  limbs. 
The  laws  of  duplication,  including  intra foetation,  are  now 
well  understood,  and  the  gigantic  growth  of  limbs  or  parts 
of  limbs,  akromegaly  and  macroglossia,  are  as  important 
in  the  life  of  the  born  as  they  are  interesting  from  the 
point  of  view  of  embryological  development.  , 

Many  symptoms  of  rhachitis,  syphilis,  and  haemophilia 
cannot  be  understood  except  in  their  embryological  connec- 
tion. The  same  is  valid  in  regard  to  congenitally  dislocated 
and  horseshoe  kidney,  and  transposition  of  the  viscera. 
Insufficient  closure  of  embryonic  fissures  explains  encepha- 
locele,  porencephaly,  spina  bifida,  bifid  uvula  and  epiglottis, 
cleft  palate,  lips,  and  cheeks,  pharyngeal  fistulae,  hernia, 
and  the  communications  between  the  intestinal  tract  and  the 
uro-genital  organs,  and  the  persistency  and  patency  of  the 
urachus. 

Inflammatory  processes  give  rise  to  spontaneous  amputa- 
tion, the  adhesions  of  the  placenta  to  the  head,  to  the  most 
severe  forms  of  obstructions  and  defects  in  the  intestine,  to 
the  stenosis  of  the  pulmonary  artery,  the  aorta,  and  the 
atrioventricular  orifice. 

I  must  not,  however,  multiply  examples  of  the  intimate 
correlation  between  embryology  and  the  malformations  and 

49 


DR.    JACOBI'S    WORKS 

diseases  of  the  child.  These  few  instances,  I  believe,  will 
suffice  to  show  to  what  extent  the  most  exact  and  special 
study  of  the  anatomy,  physiology,  and  pathology  of  the  child 
is  a  connecting  link  between,  and  the  safest  foundation  of, 
a  number  of  the  most  important  branches  of  medical  re- 
search. Indeed,  if  all  the  teaching  obtained  from  pedology 
and  pediatrics  could  be  disjoined  from  those  branches, 
these  latter  would  be  stripped  of  their  best  material. 
Though  the  history  of  pediatrics  is  but  a  brief  one,  it  can 
safely  be  stated  that  those  specialties  have  been  to  a 
great  part  feeding  on  and  been  built  up  by  the  observations 
and  investigations  of  men  specially  interested  in  the  dis- 
eases of  children.  You  will  find,  when  you  look  over  the 
programmes  of  the  nine  associations  which  now  form  the 
American  Congress  year  after  year,  that  topics  which  in 
future  will  be  the  legitimate  province  of  the  American 
Pediatric  Society,  have  attracted  much  of  their  attention. 

From  the  first  hour  of  life  the  infant  requires  special 
study.  Its  diet  has  been  a  source  of  ever-watchful  re- 
search on  the  part  of  many  of  the  best  minds.  In  modern 
times,  Zweifel,  Korowin,  Biedert,  Bouchard, — not  to  men- 
tion A.  V.  Meigs  and  Rotch  among  us, — have  deserved 
well  of  the  subject.  Not  only  diet,  however,  and  indi- 
vidual hygiene  have  been  studied  on  the  child;  the  most 
vital  questions  of  public  hygiene  are  also  connected  with 
pediatrics  most  intimately.  Besides  such  as  every  think- 
ing man  is  deeply  concerned  in,  it  is  mainly  two  topics 
that  attract  attention  of  those  who  take  an  interest  in 
children.  I  allude  to  the  school  and  to  constitutional  dis- 
eases. My  remarks  to-day  can  be  but  fragmentary;  still,  I 
must  not,  both  in  the  interest  of  our  science  and  of  hu- 
man society,  omit  to  emphasize  the  fact  that  it  still  appears 
as  if  our  schools  were  establishments  organized  to  produce 
near-sightedness,  scoliosis,  anaemia,  and  both  physical  and 
intellectual  exhaustion.  Contrary  to  the  treatment  a  colt 
receives  at  the  hands  of  its  owner,  human  society,  or  the 
state,  permits  or  directs  that  the  powers  of  a  child  should 
be  rendered  unfit  for  its  future  functions,  physical,  mental, 
and  moral,  for  these  three  are  indelibly  interwoven.  It 
requires  physical  and  mental  education  to  fertilize  the  soil 

50 


PEDIATRICS    AND    GENERAL    MEDICINE 

for  the  evolution  of  morals.  Thus  the  physician,  and  par- 
ticularly he  who  makes  pediatrics  his  special  study,  is  a 
pedagogue  by  profession.  The  question  of  school-house 
building  and  school-room  furniture,  the  structure  of  bench 
and  table,  the  paper  and  type  in  the  books,  the  number 
of  school  hours  for  the  average  child  and  the  individual 
pupil,  the  number  and  length  of  recesses,  the  hours  and 
duration  of  intervening  meals,  the  alternation  of  mental 
and  physical  training,  the  age  at  which  the  average  and 
the  individual  child  should  be  first  sent,  have  been  too 
long  decided  by  school-boards  consisting  of  coal-merchants, 
carpenters,  cheap  printers,  and  undertaught  or  overaged 
school-mistresses,  not,  however,  of  physicians.  The  health 
and  vigor  of  the  American  child  in  early  years  seems,  ac- 
cording to  Bowditch,  superior  to  those  of  the  European. 
Why  is  the  youth  and  maiden,  particularly  the  latter,  so 
inferior?  Why  is  it  that  anaemia  and  neuroses  eat  the  mar- 
row of  the 'land,  and  undermine  the  future  of  the  country 
by  degenerating  both  the  workers  and  thinkers  of  the  com- 
munity, and  the  future  mothers?  If  there  is  a  country  in 
the  world  with  a  great  destiny  and  a  grave  responsibility, 
it  is  ours.  Its  self-assumed  destiny  is  to  raise  humanitarian 
and  social  development  to  a  higher  plane  by  amalgamating, 
humanizing,  and  civilizing  the  scum  of  all  the  inferior  races 
and  nationalities  which  are  congregating  under  the  folds 
of  our  flag.  Unless  the  education  and  training  of  the  young 
is  carried  on  according  to  the  principles  of  a  sound  and  sci- 
entific physical  and  mental  hygiene,  neither  the  aim  of  our 
political  institutions  will  ever  be  reached  nor  the  United 
States  fulfil  its  true  manifest  destiny.  That  manifest  des- 
tiny is  not  so  much  the  political  one  of  excluding  Euro- 
peans from  our  continent, — North  or  South, — for  indeed 
the  participation  of  European  civilization  in  the  gradual 
work  of  removing  barbarism  ought  to  be  very  welcome, — 
but  of  raising  the  standard  of  physical  and  mental  health 
to  possible  perfection,  and  thereby  contributing  to  the  wel- 
fare and  happiness  of  the  people. 

Another  subject  in  which,  for  the  same  reason,  pedology 
and  pediatrics  are  profoundly  interested  is  that  referring  to 
constitutional  and  infectious  diseases.     Most  of  them  belong 

51 


DR.    JACOBI'S    WORKS 

to  early  life,  and  therefore  interest  you  in  this  society.  The 
vast  majority  of  them  can  be  avoided,  mortality  greatly 
diminished,  and  ill-health  resulting  therefrom  prevented. 
Ninety-nine  cases  out  of  every  hundred  of  rhachitis  need 
not  exist.  Before  we  were  overrun  with  the  poverty-stricken 
population  of  Europe,  rhachitis  was  hardly  known  among 
us.  Unless  the  social  position  of  the  many  be  improved 
and  the  laws  of  hygiene  und-erstood  and  obeyed,  it  will  in- 
crease until  we  shall  be  on  a  level  with  Ireland,  Switzer- 
land, and  Northern  Italy.  Where  the  prevention  of  syphi- 
lis lies,  or  ought  to  lie,  we  fully  know.  How  we  could 
avoid  dysentery  and  typhoid,  the  number  of  which  increases 
with  the  size  of  tenements,  the  insufficiency  of  sewers,  with 
the  number  of  large  summer  hotels,  and  defective  drain- 
age, we  thoroughly  appreciate.  Scarlatina,  morbilli,  diph- 
theria, whooping-cough,  need  not  destroy  or  maim  hun- 
dreds of  thousands  if  contagion  were  avoided;  and,  un- 
less that  be  done,  mankind,  state,  town,  have  not  per- 
formed the  most  rudimentary  function  of  their  existence. 
After  all,  we  need  not  boast  of  our  civilization,  which  in- 
deed requires  healing  and  mending  both  from  a  social 
and  medical  aspect. 

If  we  would  but  concentrate  our  means  for  fighting  pre- 
ventable disease  and  death  as  they  concentrate  them  in  Eu- 
rope for  the  purpose  of  preparing  for,  and  carrying  on, 
wars !  If  we  did,  we  should  save  as  many  hundred  thou- 
sands as  they  seek  to  destroy.  If,  besides,  but  every  phy- 
sician knew  and  appreciated  his  duty  and  his  honorable 
vocation,  which  consists  in  preventing  and  curing  disease, 
and  spending  his  best  efforts  in  ameliorating  human  exist- 
ence !  What,  then,  shall  we  say  of  those  of  our  brethren 
who  do  not  feel  it  below  their  dignity  to  study  electricity, 
or  to  make  believe  they  do,  for  the  avowed  purpose  of  sup- 
planting the  hangman.'' 

Questions  of  public  hygiene  and  medicine  are  both  profes- 
sional and  social.  Thus,  every  physician  is  by  destiny  a 
"  political  being "  in  the  sense  in  which  the  ancients  de- 
fined the  term, — viz.,  a  citizen  of  a  commonwealth,  with 
many  rights  and  great  responsibilities.  The  latter  grow 
with  increased  power,  both  physical  and  intellectual.     The 

52 


PEDIATRICS    AND    GENERAL    MEDICINE 

scientific  attainment  of  the  physician  and  his  appreciation 
of  the  source  of  evil  enable  him  to  strike  at  its  root  by  ad- 
vising aid  and  remedies.  Such  increase  of  knowledge  as 
the  combined  efforts  of  the  members  of  the  American  Pedi- 
atric Societ}^  can  result  in  from  year  to  year,  such  interest 
as  it  can  raise  in  its  own  labor,  such  impetus  as  it  can  give 
to  the  profession  at  large  in  the  direction  of  special  re- 
search, such  power  as  it  can  exert  on  the  instruction  in 
pediatrics  of  students  in  the  medical  schools,  such  influ- 
ence as  it  may  have  among  the  wealthy  public  with  a 
view  to  establish  and  endow  special  hospitals  for  infants 
and  children  in  proving  beneficial  to  all  branches  of  medi- 
cine, will  be  an  everlasting  blessing  to  mankind. 


53 


THE  HISTORY  OF  PEDIATRICS  AND  ITS  RE- 
LATION TO  OTHER  SCIENCES  AND  ARTS 

The  most  human  of  all  the  gods  ever  created  by  the 
fancy  or  the  religious  cravings  of  mortal  man  was  Phoebus 
Apollo.  It  was  he  that  gave  its  daily  light  to  the  awaken- 
ing world,  flattered  the  senses  of  the  select  with  music, 
filled  the  songs  of  the  bards  and  the  hearts  of  their  hearers 
with  the  rhythm  and  wonders  of  poetry,  that  inspired  and 
reveled  with  the  muses  of  the  Parnassus,  cheered  the  world 
with  the  artistic  creations  of  the  fertile  brains  and  skil- 
ful hands  of  a  Zeuxis  and  Phidias^ — he,  always  he,  that 
inflicted  and  healed  warriors'  wounds  and  sent  and  cured 
deadly  diseases. 

In  the  imagination  of  a  warm-hearted  and  unsophis- 
ticated people  it  took  a  god  to  embrace  and  bestow  all 
that  is  most  beneficent  and  sublime — physical,  moral,  and 
mental  light  and  warmth;  the  sun,  the  arts,  poetry,  and 
the  most  human  and  humane  of  all  sciences  and  arts, 
namely,   medicine. 

Ancient  gods  no  longer  direct  or  control  our  thoughts, 
feelings,  and  enjoyments,  either  physical  or  intellectual. 
The  kinship  and  correlation  of  hypotheses  and  studies, 
experience  and  knowledge  are  in  the  keeping  of  the  phi- 
losophical mind  of  man,  who  is  both  their  creator  and 
beneficiary.  To  demonstrate  this  rational  affinity  of  all 
the  sciences  and  arts,  some  far-seeing  men  planned  this 
great  Congress.  The  new  departure — in  the  arrangement 
for  it — ^should  be  an  example  to  future  general  and  special 
scientific  gatherings.  Indeed,  some  of  its  features  were 
adopted  by  the  organization  committee  of  the  International 
Medical  Congress  which  was  to  take  place  at  St.  Louis, 
but  was  given  up  on  account  of  the  limited  time  at  the 
disposal  of  the  great  enterprise. 

Congresses  are  held  for  the  purpose  of  comparing  and 
guarding    diversified    interests.     A    free    political    life    re- 

55 


DR.    JACOBI'S    WORKS 

quires  them  for  the  consulting  of  the  needs  of  all  classes. 
Scientific  congresses  are  convened  to  gather  and  collate 
the  varied  opinions,  experiences  and  results  of  many  men, 
and  to  create  or  renew  in  the  young  and  old  the  enthusi- 
asm of  youth.  Their  number  has  increased  with  the 
modern  differentiation  of  interests  and  studies.  Special- 
ization in  medicine  is  no  longer  what  it  was  in  old  Egypt, 
namely,  the  outgrowth  of  the  all-pervading  spirit  of  castes 
and  sub-classifications,  but  as  well  the  consequence  as  the 
source  of  modern  medical  progress.  It  is  difficult,  how- 
ever, to  say  where  specialization  ends  and  over-special- 
ization begins,  or  to  what  extent  specialization  in  medicine 
is  the  result  of  mental  and  physical  limitation  or  of  the 
spirit  of  deepening  research;  or,  on  the  other  hand,  of  in- 
dolence or  of  greed;  or  whether,  while  specialization  ben- 
efits medical  science  and  art,  it  lowers  the  mental  horizon 
of  the  individual,  and  either  cripples  or  enhances  his  use- 
fulness in  the  service  of  mankind.  For  that  is  what  med- 
ical science  and  art  are  for.  Jose  de  Letamendi  is  perhaps 
correct  when  he  says  that  a  man  who  knows  nothing  but 
medicine  does  not  even  know  medicine.  What  shall  we 
expect,  then,  of  one  who  knows  only  a  small  part  of  med- 
icine and  nothing  beyond  ? 

Congresses  in  general  have  been  of  two  kinds.  They 
are  called  by  specialists  for  specialists,  or  they  meet  for 
the  purpose  of  removing  or  relieving  the  dangers  of  lim- 
itation. This  is  what  explains  the  great  success  of  inter- 
national and  national  gatherings,  such  as  the  German, 
British,  American,  and  others,  and  what  has  given  the 
Congress  of  American  Physicians  and  Surgeons  with  its 
triennial  Washington  meetings  its  broadening  and  chasten- 
ing influence. 

Nor  are  medical  meetings  the  only  attempts  at  linking 
together  what  has  a  tendency  to  get  disconnected.  Look 
at  our  literature.  The  rising  interest  in  the  history  of 
medicine  as  exhibited  in  Europe  and  lately  also  among 
us,  and  individual  contributions,  such  as  Gomperz's  great 
book  on  Greek  thinkers;  or  even  lesser  productions,  such 
as  Eymin's  Medecins  et  Philosophes,  1904;  or  the  impor- 
tant pictorial   works    of   Charcot,    Richet,    and    Hollander, 

56 


HISTORY    OF    PEDIATRICS 

prove  the  correlation  of  medicine  with  history,  philoso- 
phy and  art. 

Our  special  theme  is  the  history  of  Pediatrics  and  its 
relations  to  other  specialties,  sciences  and  arts.  Now 
Friedrich  Ludwig  Meissner's  Grundlage  der  Literatur  der 
Padiatrik,  Leipzig,  1850,  contains  on  246  pages  about 
7,000  titles  of  printed  monographs  written  before  1849 
on  diseases  of  children,  or  some  subject  connected  with 
pedology.  Of  these,  2  were  published  in  the  fifteenth 
century,  16  in  the  sixteenth,  21  in  the  seventeenth,  75 
in  the  eighteenth.  P.  Bagellardus  de  aegritubinibus 
puerorum,  1487,  and  Bartholomeus  Metlinger,  "  Ein  vast 
niitzlich  Regiment  der  jungen  Kinder,"  Augsburg,  1473, 
opened  the  printed  pediatric  literature  of  Europe.  In 
the  sixteenth  century,  Sebastianus  Austrius,  de  puerorum 
morbis,  Basileae,  1549,  and  Hieronymus  Mercurialis,  de 
morbis  puerorum  tractatus,  1583,  are  facile  principes;  in 
the  eighteenth,  Th.  Harris,  de  morbis  infantum,  Amstelo- 
dami,  1715;  Loew,  de  morbis  infantum,  1719;  M.  Andry, 
I'orthopedie  ou  I'art  de  prevenir  et  corriger  dans  les  en- 
fants  les  difformites  du  corps,  1741;  Nils  Rosen  de 
Rosenstein,  1752;  E.  Armstrong,  An  Essay  of  Diseases 
most  Fatal  to  Infants,  1768;  and  M.  Underwood,  Treat- 
ise on  the  Diseases  of  Children,  1784;  also  Huf eland, 
established  pediatrics  as  a  clinical  entity;  while  Edward 
Jenner,  1798,  An  Inquiry  into  the  Causes  and  Effects  of 
the  Variolae  Vaccinae,  opened  the  possibilities  of  a  radical 
prevention  of  infectious  and  contagious  diseases,  the  very 
subject  which,  a  century  later,  is  engaging  the  best  minds 
and  a  host  of  assiduous  workers  in  the  service  of  plague- 
stricken    mankind. 

In  the  United  States  pediatrics  was  taught  in  medical 
schools,  or  was  expected  to  be  taught,  by  the  professors  of 
obstetrics  and  the  diseases  of  women  and  children.  The 
reorganization  of  the  New  York  Medical  College  in  East 
Thirteenth  street  facilitated  the  creation,  in  I860,  of  a 
special  clinic  for  the  diseases  of  the  young.  Instead  of  the 
united  gynaecologic  and  obstetric  clinics  held  by  Bed- 
ford, Oilman,  and  G.  T.  Elliott  in  their  respective  medical 
colleges,  there  was  a  single  clinic  for  the  diseases  of  the 

57 


DR.    JACOBI'S    WORKS 

young  exclusively.  When  the  Civil  War  caused  the  Col- 
lege to  close  its  doors  forever,  in  1865,  they  transferred  the 
clinic  to  the  University  Medical  College,  and  in  1870  to 
the  College  of  Physicians  and  Surgeons.  Meanwhile,  other 
medical  schools  imitated  the  example  thus  presented. 
The  teachers  were  classed  amongst  the  clinical  professors; 
only  in  those  schools  which  are  forming  part  of  universi- 
ties and  are  no  longer  proprietary  establishments,  a  few 
now  occupy  the  honored  position  of  full  professors;  in  a 
very  few  the  professor  of  pediatrics  is  a  full  member  of 
the   "  faculty." 

In  the  English  Colonies  of  America  the  earliest  treatise 
on  a  medical,  in  part  pediatric  subject  was  a  broadside, 
12  inches  by  17.  It  was  written  by  the  Rev.  Thomas 
Thatcher,  and  bears  the  date  January  21,  1677-8.  It  was 
printed  and  sold  by  John  Foster,  of  Boston.  The  title 
is  "  a  brief  rule  to  guide  the  common  people  of  New  Eng- 
land how  to  order  themselves  and  theirs  in  the  Small- 
Pocks,  or  measles."  A  second  edition  was  printed  in 
1702. 

Before  and  about  the  same  time  in  which  American 
pediatrics  received  its  first  recognition  at  the  hands  of  the 
New  York  Medical  College,  European  literature  furnished 
a  new  and  brilliant  special  literature.  France,  which  al- 
most exclusively  held  up  the  flag  of  scientific  medicine  dur- 
ing the  first  forty  years  of  the  eighteenth  century,  fur- 
nished in  C.  Billard's  Traite  des  maladies  des  enfants 
nouveau-nes,  1828,  and  in  Rilliet's  and  Barthez's  Traite 
clinique  et  pratique  des  maladies  des  enfants,  1838-43, 
standard  works  which  were  examples  of  painstaking  re- 
search and  fertile  observation.  England,  which  produced 
in  1801  I.  Cheyne's  Essays  on  the  diseases  of  children, 
gave  birth  to  Charles  West's  classical  lectures  on  the  dis- 
eases of  infants  and  children  in  1848,  and  F.  Churchill's 
treatise  in  1850. 

The  German  language  furnished  a  master-work  in  Bed- 
nar's  die  B^rankheiten  der  Neugebornen  and  Sauglinge, 
1850-53.  A.  Vogel  and  C.  Gerhardt,  both  general  clinical 
teachers,  gave  each  a  text-book  in  I860,  Henoch  irr  1861; 
and  Steffen  in  1865-70  published  a  series  of  classical 
essays. 

58 


HISTORY    OF    PEDIATRICS 

The  number  of  men  interested  in  the  study  and  teach- 
ing of  pediatrics  grew  in  proportion  to  the  researches  and 
wants  of  the  profession  at  large.  That  is  why  three  large 
and  influential  cyclopedias,  the  works  of  many  authors, 
found  a  ready  market,  namely,  C.  Gerhardt's  Handbuch 
der  Kinder-Krankheiten,  1877-93;  John  M.  Keating's 
Cyclopedia  of  the  Diseases  of  Children,  Medical  and  Sur- 
gical, 1889-90,  and  I.  Grancher's  and  I.  Comby's  Traite 
des  Maladies  des  Enfants,  in  five  volumes,  the  second  edi- 
tion of  which  is  being  printed  this  very  year. 

The  collective  and  periodic  literature  of  pediatrics  be- 
gan at  a  comparatively  early  time.  There  was  a  period 
towards  the  end  of  the  eighteenth  century  when  the  in- 
fluence of  Albrecht  von  Haller  seemed  to  start  a  new  life 
for  German  medical  literature  before  it  lost  itself  again 
in  the  intellectual  darkness  of  Schelling's  natural  philos- 
ophy, from  which  it  took  all  the  powers  of  French  en- 
thusiasm and  research,  and  the  epoch-making  labors  of 
Skoda,  Rokitansky,  and  finally  Virchow,  to  resuscitate  it. 
About  that  early  time  of  Haller,  there  appeared  in  Lieg- 
nitz,  1793,  a  collection  of  interesting  treatises  on  some 
important  diseases  of  children  (Sammlung  interessanter 
Abhandlungen  iiber  etliche  wichtige  Kinderkrankheiten). 
France  followed  in  1811  with  a  collection  bearing  the  title 
"  La  Clinique  des  Hopitaux  des  enfants,  et  revue  retros- 
pective medico-chirurgicale  et  hygienique.  Publiees  sous 
les  auspices  et  par  les  medecins  et  chirurgiens  des  hopitaux 
consacres  aux  maladies  des  enfants."  Next  in  order  are 
five  volumes  of  Franz  Joseph  von  Metzler's  Sammlung 
auserlesener  Abhandlungen  iiber  Kinderkrankheiten,  1833- 
36.  Twelve  fascicles  under  the  title  AnalekteiT  iiber  Kin- 
derkrankheiten oder  Sammlung  ausgewahlter  Abhandlun- 
gen iiber  die  Krankheiten  des  Kindlichen  Alters ;  la  clinique 
des  Hopitaux  des  enfants,  Redacteur  en  chef  Vanier, 
Paris,  1841;  and  I.  Behrend  and  A.  Hildebrandt,  Journal 
fiir  Kinderkrankheiten,  which  appeared  regularly  from 
1843  to  1872.  It  gave  way  to  the  Jahrbuch  fiir  Kinder- 
heilkunde,  which  has  appeared  in  quick  and  regular  succes- 
sion from  1858  to  the  present  time.  Three  series  of  Aus- 
trian Journals  between  1855  and  1876  consisted  of  a  dozen 
volumes  only.     They  contain  among  other  important  con- 

59 


DR.    JACOBI'S    WORKS 

tributions  the  very  valuable  essay's  of  Ritter  von  Ritter- 
shayn,  who  deserved  more  recognitioiT  during  his  life  and 
more  credit  after  his  death,  for  his  honesty,  industry  and 
originality,  than  he  attained. 

Special  pediatric  journals  have  multiplied  since.  The 
United  States  has  two,  France  three,  Germany  five,  Italy 
two,  Spain  one.  As  long  as  they  are  taken  by  the  pro- 
fession we  should  not  speak  of  over-production.  I  at- 
tribute their  existence  to  the  general  conviction  that  there 
is  no  greater  need  than  of  the  distribution  of  knowledge 
of  the  prevention  and  cure  of  the  diseases  of  the  young. 
The  literature  of  pediatrics  seems  to  prove  it.  Not  7,000 
as  before  1850,  not  even  70,000  titles  of  books,  pamphlets, 
and  magazine  articles   exhaust  the  number. 

Pediatric  societies  have  increased  at  the  same  rate.  The 
American  Medical  Association  and  the  British  Medical 
Association  founded  each  a  section  25  years  ago,  the  New 
York  Academy  of  Medicine,  1886.  The  American 
Pediatric  Society  was  founded  in  1889,  the  Gesellschaft 
fiir  Kinderheilkunde  connected  with  the  German  Gesell- 
schaft der  Aerzte  and  Naturforscher  in  1883,  the  English 
Society  for  the  Study  of  Disease  in  Children,  in  1900. 
There  are  pediatric  societies  in  Philadelphia,  in  the  State 
of  Ohio,  in  Paris,  Kiew,  St.  Petersburg,  and  many  places, 
all  of  them  engaged  in  earnest  work  which  is  exhibited  in 
volumes  of  their  own  or  in  the  magazines  of  the  profession. 
If  we  add  the  annual  reports  of  hundreds  of  public  in- 
stitutions, which  are  so  numerous  indeed  that  a  large  vol- 
ume of  S.  Hiigel,  "  Beschreibung  sammtlicher  Kinderheil- 
anstalten  in  Europa,"  was  required  as  early  as  1848  to 
enumerate  them;  and  an  enormous  number  of  text-books 
of  masters,  and  of  such  as  are  anxious  to  become  so,  and 
monographs,  and  essays,  and  lectures,  and  notes  prelimi- 
nary and  otherwise,  which  fill  the  magazines  that  most  of 
us  take  or  see,  and  some  of  us  read — we  may  form  an  \dci 
to  what  extent  a  topic  formerly  neglected  has  taken  hold 
of  the  conscience  and  the  imagination  of  the  medical 
public. 

Before  1769  there  was  no  institution  specially  provided 
for  sick  children.     They  were  admitted  now  and  then  to 

60 


HISTORY    OF    PEDIATRICS 

foundling  institutions  and  general  hospitals.  In  that  year 
Dr.  G.  Armstrong  established  a  dispensary  in  London, 
which  was  carried  on  until  he  died.  A  similar  institution 
was  founded  in  Vienna  by  Dr.  Marstalier,  in  1784.  Goelis 
took  charge  of  it  in  ITQ'i,  L.  Politzer' developed  it,  and  it 
is  still  in  existence.  Before  the  French  Republic  was 
strangled,  it  founded  the  first  and  largest  child's  hospital 
in  Europe,  the  Hopital  des  Enfants  malades,  in  1802. 
The  Nicolai  Hospital  was  established  in  St.  Petersburg, 
in  1834,  by  Dr.  Friedburg;  the  St.  Anne's  Child's  Hos- 
pital, in  Vienna,  1837,  by  Dr.  Ludwig  Mauthner;  and  the 
Poor  Children's  Hospital,  of  Buda  Pesth,  in  1839,  by 
Dr.  Schopf  Merei,  who  afterwards  founded  and  directed 
the  Child's  Hospital  of  Manchester,  England. 

Since  that  time  the  increasing  interest  in  the  diseases 
of  children  on  the  part  of  humanitarians  and  of  physi- 
cians and  teachers  has  multiplied  children's  hospitals. 
Most  of  them  are  small,  but  they  are  numerous  enough 
both  to  exhibit  and  disseminate  the  sense  of  responsibility 
to  the  sick  and  to  the  necessities  of  teaching.  The  United 
States  has  been  the  last  country  to  participate  in  these 
endeavors.  The  mostly  proprietary  medical  schools  did 
not  find  pediatric  teaching  to  their  advantage,  and  it  took 
the  hearts  and  purses  of  the  public  a  long  time  to  be 
opened.  The  waves  of  humanitarianism,  sometimes  directed 
by  a  church,  and  the  demands  of  science  have  finally  over- 
come previous  indolence.  There  are  many  general  hos- 
pitals that  gradually  opened  special  children's  wards. 
You  find  pediatric  hospitals  in  some  of  the  larger  cities — 
New  York,  Boston,  Philadelphia,  Albany,  St.  Louis,  and 
others.  It  has  so  happened,  however,  that  real  specialties 
have  appealed  more  to  the  general  sympathy  than  pedia- 
trics. That  is  why  the  number  of  beds  in  orthopedic  and 
other  special  hospitals  are  mostly  favored.  Practical 
teaching  has  not  been  extensive.  Children's  hospitals  that 
should  be  used  for  that  purpose,  and  that  are  directly  con- 
nected with  a  medical  school,  are  but  few.  It  has  taken 
the  medical  faculties,  even  of  Universities,  too  much  time 
to  appreciate  the  necessity  of  special  and  well-regulated 
bedside  teaching.     In  some  instances  lay  trustees,   guided 

61 


DR.    JACOBI'S    WORKS 

by  their  medical  advisers,  have  opened  their  wards  before 
faculties  have  consented  to  open  their  eyes.  At  the  pres- 
ent time,  however,  there  is  hardly  a  great  medical  school 
that  does  not  give  amphitheatre  or  bedside  instruction, 
either  in  a  children's  ward  of  a  general  hospital  or  in  a 
special  children's  or  babies'  hospital.  To  a  certain  extent 
the  teaching  of  pediatrics  in  a  general  hospital  has  its 
great  advantages.  It  is  not  a  specialty  like  that  of  a  spe- 
cial sense  or  a  tissue.  For  the  purpose  of  study  it  had 
to  be  segregated,  but  it  will  never  be  torn  asunder  from 
general  medicine.  Vogel  and  Gerhardt  were  both  general 
clinicians. 

The  comparative  anatomy  and  physiology,  hygiene, 
etiology,  and  nosology  of  pediatrics  have  been  discussed 
before  you  by  one  of  the  most  prominent  pediatrists  of 
our  era.  It  will  be  my  privilege  to  explain,  as  far  as  time 
will  permit,  its  relation  to  general  medicine,  to  embryology 
and  teratology,  obstetrics,  hygiene,  and  private  and  public 
sanitation,  to  therapeutics  both  pharmacal  and  operative, 
and  to  the  specialties  of  otology,  ophthalmology,  dermatol- 
ogy and  the  motor  system,  to  pedagogy,  to  neurology  and 
psychiatry,  forensic  medicine  and  criminology,  and  to  social 
politics. 

Infancy  and  childhood  do  not  begin  with  the  day  of 
birth.  From  conception  to  the  termination  of  foetal  life 
evolution  is  gradual.  The  result  of  the  conception  de- 
pends on  parents  and  ancestors.  Nowhere  are  the  laws  of 
heredity  more  perceptible  than  in  the  structure  and  nature 
of  the  child.  Physical  properties,  virtues  and  sins,  and 
tendencies  to  disease  may  not  stop  even  with  the  third 
or  fourth  generation.  Hamburger  and  Osier  trace  an 
angio-neurosis  through  six  generations,  the  first  case  in 
the  series  being  observed  by  Benjamin  Rush.  In  many 
instances  still-births,  early  diseases,  atrophy,  and  undue 
mortality  of  the  young  depend  on  antenatal  happenings. 
The  condition  and  diet  of  the  mother  influences  her  off- 
spring. The  danger  of  a  contracted  pelvis,  and  the 
necessity  of  premature  delivery  may  be  obviated  by  the 
restriction  of  the  diet,  or  even  by  appropriate  (thyroid 
and  other)   medication   of  the  pregnant  woman.     Experi- 

62 


HISTORY    OF    PEDIATRICS 

ence  and  experiment  tell  the  same  story.  The  continued 
practice  of  preventing  conception  causes  endometritis. 
Alcoholism  causes  chronic  placentitis,  premature  confine- 
ment, or  still-birth.  So  does  chronic  phosphorus  and  lead 
poisoning.  Fortunately,  however,  the  usual  medication 
resorted  to  during  labor  is  rarely  dangerous,  for  even 
morphine  or  ergot  doses  given  to  the  parturient  woman  on 
proper  indications  affect  the  newly-born  rarely,  and  chloro- 
form anesthesia  almost  never. 

Scanty  amniotic  liquor,  by  the  prevention  of  free  intra- 
uterine excursions,  may  cause  club-foot;  or  close  contact 
of  the  surfaces  of  the  embryo  and  the  membranes  give 
rise  to  adhesions  of  the  placenta  and  the  head,  to  filaments 
and  bands  whose  pressure  or  traction  produces  grooving 
or  amputation  of  limbs,  cohesion  of  toes  or  fingers,  um- 
bilical meningeal,  encephalic,  or  spinal  hernia;  not  in 
extra-uterine  pregnancy  only,  where  such  occurrences  are 
very  frequent.  Even  the  majority  of  harelips  and  fis- 
sured palates  have  that  origin.  Arrests  of  development 
and  fcEtal  inflammation  are  the  headings  under  which  most 
of  the  anomalies  of  the  newly-born  may  be  subsumed; 
congenital  diseases  of  the  ear  and  of  the  heart  may  result 
from  either  cause  or  from  both.  Obstructions  of  the  in- 
testines, the  rare  closures  of  the  oesophagus,  the  ureter, 
and  the  urethra,  with  hydro-nephrosis  and  cystic  degen- 
eration of  the  kidneys  are  probably  more  due  to  excessive 
cell  proliferation  in  the  minute  original  grooves  than  to 
inflammation. 

The  insufficient  closures  of  normal  embryonic  fissures  or 
grooves  explain  many  cases  of  spina  bifida,  many  of 
encephalocele,  most  of  the  split  lips  and  palates,  all  of 
porencephalus,  bifid  uvula  and  epiglottis,  pharyngeal  and 
thyroglossal  fistulae,  the  communications  between  the  in- 
testinal and  uro-genital  tracts,  and  the  persistency  and 
patency  of  the  urachus.- 

2  J.  W.  Ballantyne,  in  his  Manual  of  Antenatal  Pathology  and 
Hygiene,  190:?,  has  a  separate  chapter  on  the  relations  of  ante- 
natal pathologj-  to  other  branches  of  study,  to  general  pathology, 
to  the  biological  sciences,  such  as  anatomy,  embryology,  physiol- 
ogy, botany,  and  zoology,  and  to  the  medical,,  including  obstetrics, 

63 


DR.    JACOBI'S    WORKS 

Heredity  need  not  show  itself  in  the  production  of  a 
fully  developed  disease.  It  exhibits  itself  normally  either 
in  equality  or  resemblances,  either  total  or  partial,  of  the 
body,  or  some  one  or  more  of  its  external  or  internal  or- 
gans. In  this  way  it  may  affect  the  nervous,  the  muscular, 
the  osseous,  or  other  tissues.  That  is  why  dystrophies  in 
different  forms,  obesity,  achondroplasia,  hyperplasia,  or 
atrophy  may  be  directly  inherited,  while  in  other  cases 
the  disposition  to  degeneration  only  is  transmitted. 

Hereditary  degeneracy  is  often  caused  by  social  influ- 
ences. The  immoral  conditions  created  by  our  financial 
system  make  women  select  not  the  strong  and  hearty  and 
the  young  husband,  but  the  rich  and  old,  with  the  result 
of  having  less,  and  less  vigorous,  children.  Certain  pro- 
fessions, the  vocations  of  soldiers  and  mariners,  and  subor- 
dinate positions  of  employees  in  general,  enforce  com- 
plete or  approximative  celibacy,  with  the  same  result.  The 
nations  that  submit  to  the  alleged  necessity  of  keeping 
millions  of  men  in  standing  armies,  are  threatened  with 
a  degenerated  offspring,  for  not  only  do  they  keep  the 
strongest  men  from  timely  marriages,  but  they  increase 
prostitution  and  venereal  diseases,  with  their  dire  conse- 
quences for  men,  women,  and  progeny.  Wars  lead  to  the 
same  result  in  increased  proportion,  for  tens  and  hundreds 
of  thousands  of  the  sound  men  are  slain  or  crippled,  or 
demoralized.  Those  who  are  inferior  and  unfit  for  phy- 
sical exertions  remain  behind  and  procreate  an  inferior 
race;  those  who  believe  with  Lord  Rosebery  that  an  em- 
pire is  of  but  little  use  without  an  imperial  race  will  al- 
ways, in  the  interests  of  a  wholesome  civilization,  object 
to  the  untutored  enthusiasm  which  denounces  the  "  weak- 
ling," and  the  "  craven  cowardice  "  of  those  who  believe 
in  the  steady  evolution  of  peace  and  harmony  among^st 
men,  and,  in  sympathj'^  with  the  physical  and  moral  health 
of  the  present  and  future  generation,  will  prefer  the 
cleanly  and  washed  sportsmanship  of  an  educated  youth 
to  that  of  the  mud-streaked  and  blood-stained  man-hunter. 

public  health,  pediatrics,  medicine,  psychology,  dermatology,  sur- 
gery, orthopedics  and  medical  jurisprudence,  finally  to  gynaecology 
and  neo-natal  pathology. 

64 


HISTORY    OF    PEDIATRICS 

A  great  many  diseased  conditions  cannot  be  thoroughly 
understood  unless  they  be  studied  in  the  evolving  being. 
Tumors  are  rarely  inherited,  but  many  of  them  are 
observed  in  early  life.  Lymphoma,  sarcoma,  also  lipoma 
and  carcinoma,  and  cystic  degeneration,  are  observed  at 
birth,  or  within  a  short  time  after,  and  seem  to  favor 
Cohnheim's  theory,  according  to  which  many  owe  their 
origin  to  the  persistence  in  an  abnormal  location  of  em- 
bryonic cells.  This  theory  does  not  exclude  the  fact  that 
congenital  tumors  may  remain  dormant  for  years  or  de- 
cades and  not  destroy  the  young. 

So  much  on  some  points  connected  with  embryology  and 
teratology.  The  connection  with  obstetrical  practice  is 
equally  intimate.  Three  per  cent,  of  all  the  mature  living 
foetuses  are  not  born  into  postnatal  life  this  very  day.  To 
reduce  the  mortality  even  to  that  figure,  it  has  taken  much 
increase  of  knowledge  and  improvement  in  the  art  of 
obstetrics  to  such  an  extent  that  it  has  become  possible  by 
Cesarean  section  not  only  to  save  the  foetus  of  a  living, 
but  also  of  a  dead  mother,  for  the  foetus  in  her  may  survive 
the  dying  woman. 

But  after  all,  many  a  baby  would  be  better  off,  and  the 
world  also,  if  it  had  died  during  labor.  There  are  those, 
and  not  a  few,  who  are  born  asphyxiated  on  account  of 
interrupted  circulation,  compression  of  the  impacted  head, 
or  meningeal  or  encephalic  hemorrhage,  which  destroys 
many  that  die  in  the  first  week  of  life.  Those  who  are  not 
so  taken  away  may  live  as  the  result  of  protracted 
asphyxia  only  to  be  paralytic,  idiotic,  or  epileptic.  Many 
times  in  a  long  life  have  I  urged  upon  the  practitioner  to 
remember  that  every  second  added  to  the  duration  of 
asphyxia  adds  to  the  dangers  either  to  life  or  to  an  im- 
paired human  existence.  Besides  fractures,  facial  or 
brachial  paralysis,  cephalhaematoma  and  haematoma  of  the 
sterno-cleido  mastoid  muscle,  gonorrheal  ophthalmia,  with 
its  dangers  to  sight  and  even  life,  may  be  daily  occurrences 
in  an  obstetrician's  life.  All  such  cases  prove  the  insuf- 
ficiency of  knowledge  without  art,  or  of  art  without  knowl- 
edge, and  the  grave  responsibility  of  the  practical  obste- 
trician.     To   lose   a   newly-born   by   death   causes    at  least 

65 


DR.    JACOBI'S    WORKS 

dire  bereavement;  to  cripple  his  future  is  not  rarely  crim- 
inal  negligence. 

Within  a  few  days  after  birth  the  obstetrician  or  the 
pediatrist  has  the  opportunity  of  observing  all  sorts  of 
microbic  infections,  from  tetanus  to  hemorrhages  or  gan- 
grene, and  the  intense  forms  of  syphilis.  Not  an  uncom- 
mon disease  of  the  newly-born  and  the  very  young  is 
nephritis.  It  is  the  consequence,  in  many  cases,  of  what 
appears  to  be  a  common  jaundice,  or  of  uric  acid  infarc- 
tion, which  is  the  natural  result  of  the  sudden  change  of 
metabolism.  The  diverticula  of  the  colon,  as  described  by 
Hirschsprung  and  Osier,  and  what  nearly  40  years  ago 
was  characterized  as  congenital  constipation,  which  de- 
pends on  the  exaggeration  of  the  normally  excessive  length 
of  the  sigmoid  flexure,  belong  to  the  same  class.  Their 
dangers  may  be  avoided  when  they  are  understood.  Of 
the  infectious  diseases  of  the  embryo  and  the  fcEtus,  it  is 
principally  syphilis  that  should  be  considered ;  amongst 
the  acute  forms  variola  and  typhoid  are  relatively  rare. 

What  I  have  been  permitted  to  say  is  enough  to  prove 
the  intimate  interdependence  and  connection  between 
pediatrics  and  the  diseases  of  the  foetus  with  embryology 
and  teratology,  obstetrics,  and  some  parts  at  least,  of 
social  economics. 

After  birth  there  are  anomalies  and  diseases  which  are 
encountered  in  the  infant  and  child  only.  There  are  also, 
common  to  all  ages,  though  mostly  found  in  children, 
such  as  exhibit  a  symptomatology  and  course  peculiar  to 
them.  The  first  class,  besides  those  which  are  seen  in 
the  newly-born,  is  made  up  mostly  of  developmental  dis- 
eases— scrofula,  rachitis,  chlorosis.  The  actual  or  alleged 
ailments  connected  with  dentition,  most  forms  of  stomatitis, 
Bednar's  so-called  aphthae,  the  ulceration  of  epithelial 
pearls  along  the  raphe,  amygdalitis,  pharyngitis,  adenoid 
proliferations,  latero-  and  retro-pharyngeal  abscesses  be- 
long here.  Infectious  diseases,  such  as  variola,  diphtheria, 
scarlatina,  measles,  pertussis,  and  tuberculosis  of  the 
glands,  bones,  joints,  and  peritoneum  have  been  most  suc- 
cessfully studied  by  pediatrists  or  those  clinicians  who 
paid  principal  attention  to  pedology.     Meissner  prints  the 

66 


HISTORY    OF    PEDIATRICS 

titles  of  more  than  200  actual  monographs  on  scarlet  fever 
published  irr  Europe  before  1848.  Pleurisy  and  pneumonia 
of  the  young  have  their  own  symptomatology.  Empyema 
is  more  frequent  and  requires  much  more  operative  inter- 
ference. 

Tracheotomy  and  intubation  are  mostly  required  by  the 
young,  both  on  account  of  their  liability  to  oedema  of 
the  larynx  and  to  diphtheria,  and  of  the  narrowness 
of  the  larynx.  Of  invagination,  25^  occur  under  one 
year,  53;|^  under  10.  Appendicitis,  sometimes  hereditary 
and  a  family  disease,  would  long  ago  have  been  recognized 
as  a  frequent  occurrence  in  the  young  if  it  had  not  been 
for  the  difficulty,  mainly  encountered  in  the  young,  and 
sometimes  impossibility  of  its  diagnosis.  That  is  what 
we  have  been  taught  by  Hawkins  and  by  Treves,  and  lately 
by  McCosh.  Operations  on  glandular  abscesses,  osteoto- 
mies, and  other  operations  on  the  bones  and  joints,  par- 
ticularly in  tuberculosis,  and  on  malformations,  such  as 
have  been  mentioned,  require  the  skilful  hand  of  the  oper- 
ating physician  in  a  great  many  instances.  Omphalocele, 
exstrophy  of  the  bladder,  undescended  testicle,  spermatic 
hydrocele,  multiple  exostoses,  imperforate  rectum,  atresia 
of  the  vagina,  or  an  occasional  case  of  stenosed  pylorus, 
belong  to  that  class,  some  requiring  immediate  operation, 
some  permitting  of  delay.  It  is  principally  infancy  that 
demands  removals  of  angioma,  which  are  almost  all  suc- 
cessful, and  of  hygroma,  mostly  unsuccessful,  mainly 
when  situated  on  the  neck  and  resulting  from  obstruction 
of  the  thoracic  duct  sometimes  connected  with  thrombosis 
of  the  jugular  vein.  Childhood  requires  correction  of 
kyphosis  and  scoliosis,  and  operations  for  adenoids  and 
hypertrophied  tonsils,  and  furnishes  the  opportunities  for 
lumbar  puncture  and  laparotomy  in  tubercular  peritonitis ; 
also  supra-pubic  cystotomy,  and  mastoid  operations.  That 
gum-lancing  is  no  operation  indicated  or  permissible  in 
either  the  young  or  adult,  and  not  any  more  so  in  the 
former  than  in  the  latter,  is  easily  understood  by  those 
who  acknowledge  its  necessity  only  in  the  presence  of  a 
morbid  condition  of  the  gums  or  teeth,  and  not  when  the 
physiological  process  of  dentition   exhibit  no  anomaly.    It 

67 


DR.    JACOBI'S    WORKS 

scarcely  ever  does.  Altogether  operating  specialists  would 
work  and  know  very  much  less  if  a  large  majority  of  the 
cases  were  not  entrusted  to  tliem  by  the  pediatrist,  who 
recognizes  the  principle  that  those  who  are  best  fitted  to 
perform  it  should  be  trusted  with  important  medical  work. 
So  well  is  the  seriousness  and  difficulty  of  operative  pro- 
cedures, as  connected  with  diseases  of  children,  recognized 
by  experts,  that  1,500  pages  of  Gerhardt's  handbook  are 
dedicated  to  external  pathology  and  operations,  and  that 
special  works,  besides  many  monographs  by  hundreds  of 
authors,  have  been  written  by  such  masters  as  Guersant, 
Forster,  Bryant,  Giraldes,  Holmes,  St.  Germain,  Karew- 
ski,  Lannelongue,  Kirmisson,  and   Broca. 

Ear  specialists  recognize  the  fact  that  otology  is  mostly 
a  specialty  of  the  young.  The  newly-born  exhibit  changes 
in  the  middle  ear  which  are  variously  attributed  to  the 
presence  of  epithelial  detritus,  to  the  aspiration  of  foreign 
material,  or  to  an  oedema  ex  vacuo  occasioned  by  the  sepa- 
ration of  formerly  adjacent  mucous  surfaces.  Pus  is 
found  in  the  middle  ear  of  75^  of  the  still-born  or  of 
dead  nurslings.  It  contains  meconium,  lanugo,  and  vernix. 
AschofF  ^  examined  50  still-born,  or  such  as  had  lived  less 
than  two  hours;  28  of  them  had  pus  in  the  middle  ears 
(55j^).  He  also  examined  35  ifffants  that  had  lived  longer 
than  two  hours;  24  had  pus  (TOj?!).  Evidently  the  latter 
class  had  been  exposed  to  a  microbic  invasion.  The  diag- 
nosis in  the  living  infant  is  very  difficult,  mostly  impossible, 
on  account  of  the  large  size  of  the  Eustachian  tube, 
which  after  having  admitted  the  infection,  allows  the  pus 
to  escape  into  the  pharynx  and  the  rest  of  the  alimentary 
canal.  Many  of  the  newly-born  that  die  with  unexplained 
fevers  perish  from  the  septic  material,  or  its  toxins, 
absorbed  in  the  middle  ear  or  the  intestines.  Nor  are 
older  children  exempt.  Geppert  (Jahrb.  f.  Kind.,  xlv, 
1897)  found  a  latent  otitis  media  in  75^  of  all  the  in- 
mates of  the  Children's  Hospitals.  Both  latent  and  known 
otitis  is  often  connected  with  pneumonia,  or  with  pneu- 
monia and  enteritis.     In  individual  cases  it  may  be  difficult 

8  Aschoflf,  Z.  f.  Ohrenh.  Vol.  xxxi. 
68 


HISTORY    OF    PEDIATRICS 

to  decide  which  of  the  two  or  three  is  the  primary,  which 
the  secondary  affection. 

The  great  vascularity  of  the  middle  ear,  but  still  more 
the  accessibility  of  the  funnel-like  Eustachian  tube  in 
the  infant,  renders  otitis  media  very  frequent.  Schwartze's 
assertion  that  otitis  media  furnishes  22^  of  all  ear  cases 
in  general  or  special  practice  is  surely  correct.  Besides, 
difficult  hearing  is  very  frequent  in  the  young,  a  fact  of 
the  greatest  import  to  pedagogy.  As  early  as  1886  Bezold 
found  that  of  1,900  school  children  25^  had  only  one- 
third,  and  11^  of  the  others  only  one-fifth  of  normal  hear- 
ing. The  frequent  affections  of  the  nose  and  pharynx  in 
the  young  explain  these  facts  and  exhibit  the  possibilities 
of  preservation.  Finally,  the  immature  condition  of  the 
mastoid  process  and  of  the  floor  of  the  external  canal  is 
best  appreciated  by  the  practitioner,  general  or  special, 
who  deals  with  their  abscesses. 

Whether  deafmutism  is  the  result  of  consanguineous 
marriage  cannot  be  definitely  asserted.  It  is  not  often 
hereditary,  quite  often  it  appears  to  be  the  result  of  fam- 
ily alcoholism,  it  sometimes  depends  on  arrest  of  develop- 
ment and  foetal  inflammation,  but  is  more  frequently  an  ac- 
quired condition.  Not  rarely  children  are  affected  after 
they  have  been  able  to  speak.  The  majority  of  cases  are 
caused  by  cerebral  or  cerebro-spinal  inflammation.  Ac- 
cording to  Biedert,  55^  are  of  that  class,  28^  are  caused 
by  infectious  diseases  (cerebro-spinal  meningitis,  scarla- 
tina, typhoid  fever,  diphtheria,  also  variola  and  measles), 
3.3^  by  injuries,  and  only  2.5^  are  original  ear  affections. 
Thus  many  of  the  congenital  cases,  and  most  of  the  ac- 
quired, are  preventable.  More  and  more  will  our  deaf- 
mute  institutions  avail  themselves  of  this  knowledge,  and 
will  learn  how  to  teach  their  children  not  only  how  to 
read  and  write,  but  also  how  to  hear. 

Not  to  the  same,  but  to  a  great  extent,  pediatrics  and 
ophthalmology  join  hands.  Infectious  diseases,  such  as 
diphtheria,  affect  the  conjunctiva  and  sometimes  the 
cornea.  Syphilis  of  the  cornea,  with  or  without  chronic 
iritis,  is  the  form  of  parenchymatous  or  diffuse  keratitis. 
A  frequent  tumor  in  the  ej^e  of  the  young  is  glioma,  and 

69 


DR.    JACOBI'S   WORKS 

frequent  symptomatic  anomalies  are  strabismus  and 
nystagmus — both  of  them  the  results  of  a  great  many 
and  various  external  or  internal  causes,  with  sometimes 
difficult   diagnoses. 

The  connection  of  pedology  with  dermatology  is  more 
than  skin  deep;  some  of  the  most  interesting  problems 
of  the  latter  must  be  studied  on  antenatal  and  postnatal 
lines.  The  congenital  absence  of  small  or  large  parts  of 
the  surface  is  probably  due  to  amniotic  adhesions;  sebor- 
rhea and  the  mild  form  of  lichen,  also  the  furunculosis 
of  infant  cachexia  and  atheroma,  to  the  rapid  develop- 
ment, in  the  second  half  of  intra-uterine  life,  of  the 
sebaceous  follicles;  ichthj^osis,  to  the  same  and  to  a 
hypertrophy  of  the  epidermis  and  the  papillae  of  the 
corium,  sometimes  with  dilatation  of  their  blood-vessels 
and  with  sclerosis  of  the  connective  tissue.  Congenital 
anomalies,  such  as  lipoma,  sarcoma,  naevus  pigmentosus, 
open  all  the  question's  of  the  embryonal  origin  of 
neoplasms;  and  the  eruptions  on  the  infant  surface 
unclose  to  the  specialist  the  subject  of  infectious  diseases. 
We  recognize  in  the  pemphigus  of  the  palms  arrd  soles 
syphilis;  in  herpes,  gangrene,  in  what  I  have  described 
as  chronic  neurotic  pemphigus,  the  irritable  nervous 
system;  in  eczema,  constitutional  disturbances  of  the 
nutrition;  irr  erythema,  local  irritation  or  intestinal  auto- 
infection;  in  isolated  or  multiple  forms  ranging  between 
hyperaemia  and  exudation,  the  effect  of  local  irritation 
or  the  acute  or  chronic  influence  of  drugs.  A  dermatol- 
ogist who  knows  no  embryology  or  pedology,  a  pediat- 
rist  who  knows  no  dermatology,  is  anything  but  a  com- 
petent  and   trustworthy    medical    practitioner. 

The  diseases  of  the  muscles  interest  the  pediatrist,  the 
surgical  specialist,  the  orthopaedist,  the  neurologist,  to 
an  equal  extent.  Many  forms  of  myositis  are  of  infec- 
tious origin.  Amongst  the  special  forms  of  muscular 
atrophy  it  is  the  hereditary  variety  which  concerns  the 
first.  The  spinal  neuritic  atrophy,  the  myogenous, 
progressive  dystrophy,  including  the  so-called  pseudo- 
hypertrophy, Thomson's  congenital  myotonia,  and  atro- 
phic   defects    of   muscles — ^mainly    the    pectoral,    but    also 

70 


HISTORY    OF    PEDIATRICS 

the  trapezius,  quadriceps,  and  others — no  matter  whether 
they  are  primary  or  myogenous  (this  probably  always 
when  there  is  a  complication  with  progressive  dystrophy), 
are  of  special  interest  to  the  neurologist.  I  need  not  do 
more  than  mention  torticollis  in  order  to  prove  that 
neither  the  pediatrist  nor  the  orthopaedist,  nor  the  general 
surgeon  can  raise  the  claim  of  sole  ownership. 

The  relations  of  pediatrics  to  forensic  medicine  are 
very  close.  Nothing  is  more  apt  to  demonstrate  this 
than  the  immense  literature  in  every  language  on 
infanticide  and  all  the  questions  of  physiology,  physics, 
and  chemistry  connected  with  that  subject.  The  mono- 
graphs and  magazine  essays  of  the  last  two  centuries 
written  on  the  value  or  the  fallacy  of  the  lung  test  in  the 
dead  newborn  would  fill  a  small  library.  Much  atten- 
tion has  been  paid  by  physicians  and  by  forensic  authors 
to  lesions  and  fractures  of  the  newly-born  head,  and  to 
anomalies  of  the  female  pelvis  causing  them.  Apparent 
death  of  the  newly-born  and  the  causes  of  sudden  death 
in  all  periods  of  life  have  been  studied  to  such  an  extent 
as  to  render  negative  results  of  police  investigation  and 
of  autopsy  reports  less  numerous  from  year  to  year. 
Most  sudden  deaths  receiving  the  attention  of  the- 
authorities  occur  in  the  young.  There  were  (Wm. 
Wynn  Westcott  in  Brit.  M.  J.,  Nov.  7,  1903)  in 
England  and  Wales  during  ten  years  15,009  overlain 
infants;  in  1900,  1,774.  In  Liverpool,  out  of  960  inquests 
there  were  14-3  on  babies  that  had  died  of  such  suffoca- 
tion by  accident  or  malice  aforethought;  in  London,  in 
1900,  615;  in  1901,  511;  in  1902,  588.  In  London  they 
had  annually  8,000  official  inquests,  one  of  14  of  which 
were  on  overlain  infants.  The  etiology  of  sudden  deaths 
would  be  far  from  complete,  indeed  the  most  difficult 
questions  could  not  be  solved  except  by  the  facilities  fur- 
nished by  the  observations  on  the  young.  Foreign 
bodies  in  the  larynx,  beans,  shoe-buttons,  and  playthings 
generally,  even  ascarides  (Bouchut),  bones  and  pieces  of 
meat  aspirated  during  vomiting,  acute  ccdema  of  the 
glottis,  aspiration  of  a  long  uvula,  or  of  the  retracted 
tongue,  the  rupture  of  a  pharyngeal  abscess  or  of  a  suppu- 

71 


DH.    JACOBl'S    WORKS 

fating  lymphoid  body  into  the  trachea,  a  sudden  swell- 
ing of  the  thymus  in  the  narrow  space  between  the 
manubrium  and  vertebral  column,  which  at  best  measures 
only  2.2  cm.,  even  a  coryza  in  the  narrow  nose  of  a  small 
infant  filled  or  not  with  adenoids — are  causes  of  sudden 
death 

The  nervous  system  furnishes  many  such  cases.  It 
is  true  there  is  no  longer  a  diffuse  interstitial  encepha- 
litis, such  as  Jastrowitz  would  have  it,  nor  is  the  hyper- 
trophy of  the  brain  by  far  so  frequent  as  Hiittenbremaer 
taught,  but  there  are  sudden  collapses  and  deaths  by  falls 
on  the  abdomen,  by  sudden  strangulation  of  large 
herniae  and  other  shocks  of  the  splanchnic  nerve.  There 
are  sudden  and  unexplained  deaths  in  unnoticed  attacks 
of  convulsions,  in  the  first  paralytic  stage  of  laryngismus 
stridulus,  in  glottic  spasms  from  whatever  cause,  in  the 
paralysis — or,  according  to  Escherich,  laryngo-spasm — of 
what  since  Paltauf  has  been  denominated  status  lymphat- 
icus,  in  cerebral  anemia,  no  matter  whether  it  is  the 
result  of  exhaustion  or,  as  Charles  West  taught  us  60 
years  ago,  from  the  mere  change  of  position  of  a  pneu- 
monic or  otherwise  sick  baby,  when  suddenly  raised 
from  its  bed.  Or  death  may  occur  suddenly  (a  very  fre- 
quent occurrence)  in  the  heart  failure  of  parenchymatous 
degeneration  of  the  heart  muscle  as  it  occurs  in  and  after 
diphtheria,  influenza,  and  other  infectious  diseases,  or  in 
the  acute  sepsis  of  appendicitis  and  other  intraperitoneal 
affections,  whether  recognized  or  not.  For  the  absorb- 
ing power,  even  of  the  normal  peritoneum,  is  enormous. 
Of  a  very  acute  infection  ("  infectio  acutissima  "),  Wer- 
nich  spoke  as   early  as   1883. 

In  gastroenteritis,  the  terminating  broncho-pneu- 
monia may  destroy  life  quite  suddenly;  there  is  a  capil- 
lary bronchitis  of  the  very  young  with  no  cry,  no  moan, 
and  no  cough,  but  with  sudden  death;  there  are  in 
extreme  atrophy,  fatal  emboli  into  the  pulmonary,  some- 
times renal,  more  often  cerebral  arteries.  There  are  the 
cases  of  uremic  convulsions,  sudden,  with  sudden  death, 
which  are  often  taken  to  be  merely  reflected  or  "  prov- 
idential," because  the  frequency  of  acute  nephritis  in  the 

72 


HISTORY    OF    PEDIATRICS 

rtewly-born  and  the  infant,  with  its  fever  and  its  uremia, 
in  spite  of  the  publications  of  Martin  and  Ruge,  Vir- 
chow,  Orth,  Epstein,  and  my  own,  is  not  yet  fully 
appreciated.  That  is  so  much  the  more  deplorable  as 
the  diagnosis  of  nephritis  at  any  age  is  readily  made 
by  the  examination  of  the  urine,  which  is  so  easy  to 
obtain  in  the  young.  Other  suddenly  fatal  conditions, 
such  as  the  acute  or  chrome  sepsis  I  mentioned  before, 
often  quite  unsuspected,  entering  through  the  umbil- 
icus, the  intestine,  or  the  middle  ear,  are  quite  frequent. 
I  have  been  careful  not  to  mention  any  cause  of  death 
that  may  just  as  well  be  and  has  been  studied  in  the 
adult:  hemorrhages,  the  many  forms  of  sepsis  of  later 
periods  of  life,  poisons,  such  as  carbolic  acid  and  iodo- 
form, intense  cold  or  heat,  insolation,  etc.,  for  it  is  my 
duty  to  exhibit  the  relation  to  forensic  medicine  of 
pediatrics  only.  Forensic  medicine  has  to  guard  the 
interests  of  all.  Nothing  in  all  medicine  is  more  diffi- 
cult than  the  discovery  of  the  cause  of  death.  The  best 
knowledge  of  the  advanced  practitioner,  of  the  path- 
ologist, of  the  chemist,  of  the  bacteriologist,  of  the 
obstetrician,  should  be  at  the  service  of  the  people. 
Every  European  country  understands  that  and  acts  on 
that  knowledge.  Our  own  Massachusetts  has  broken 
away  from  the  coroner's  institution,  which  was  a  fit 
authority  for  a  backwoods  municipality,  but  is  so  no 
longer  for  a  cultured  people  of  eighty  millions.  Now  and 
then,  even  an  expert,  or  a  body  of  experts,  does  not  suc- 
ceed in  discovering  the  cause  of  death.  What  shall  we 
say  of  a  system  which  now  and  then  does  discover  the 
hidden  cause  of  a  sudden  death.''  When  the  New  York 
State  Legislature  six  months  ago  passed  a  bill  abolishing 
the  no  longer  competent  office  of  coroner,  our  good  cul- 
tured mayor,  a  gentleman  and  author,  vetoed  it  for  the 
reason  that  the  wew  law  was  not  perfect.  It  was  not 
pronounced  perfect  by  anybody,  no  law  is  nor  ever  was. 
That  is  why  it  appears  he  prefers  something  that  always 
was  and  is,  and  always  will  be  perfect,  namely,  the 
absurd  incompetency  and  anachronism  of  the  coroner's 
office.      That  is  perfect.       I  have  not  hesitated  to   express 

73 


DR.    JACOBI'S   WORKS 

myself  strongly  and  positively,  for  I  have  been  called 
upon  to  speak  to  you  about  the  relation  of  pediatrics  to 
other  sciences  and  arts — politics  included,  than  which 
there  is  no  more  profound  practical  and  indispensable 
science  and  art.  The  greatest  historical  legislators 
understood  that  perfectly  well,  when  they  knew  how  to 
blend  hygiene  and  religion  with  their  social  and  political 
organization. 

One  of  the  greatest  questions  which  concerns  at  the 
same  time  the  practical  statesman,  the  humanitarian 
and  the  pediatrist,  is  that  of  the  excessive  mortality  of 
the  young.  The  Paris  Academy  of  Medicine  enumer- 
ated in  its  discussions  of  1870  the  following  amongst  its 
causes:  Poverty  and  illness  of  the  parents,  the  large 
number  of  illegitimate  births,  inability  or  unwillingness 
on  the  part  of  mothers  to  nurse  their  offspring,  artificial 
feeding  with  improper  material,  the  ignorance  of  the 
parents  in  regard  to  the  proper  food  and  hygiene,  expo- 
sure, absence  of  medical  aid,  careless  selection  of  nurses, 
lack  of  supervision  of  baby  farms,  general  neglect  and 
infanticide.  If  there  be  anybody  who  is  not  quite  certain 
about  the  relationship  of  sciences  and  arts,  he  will  still 
be  convinced  of  the  correlation  and  co-operation  of  igno- 
rance, indolence,  viciousness  and  death,  and  shocked  by 
the  shortcomings  of-  the  human  society  to  which  we 
belong.  Most  of  them  should  be  avoided.  Forty  per 
cent,  of  the  mortality  of  infants  that  die  before  the  end 
of  the  first  year  takes  place  in  the  first  month.  That  is 
mostly  preventable.  A  few  years  ago  the  mortality  of 
the  infants  in  the  Mott  Street  barracks  of  New  York 
City  was  325  per  mille.  Much  of  it  is  attributable  to 
faulty  dietA 

Amongst    those    who    believe    in    the    omnipotence    of 

4  Measures  taken  for  the  purpose  of  obtaining  wholesome  milk 
are  not  quite  new.  Regulations  were  given  in  Venice,  1599,  for 
the  sale  of  milk.  Milk  and  its  products  of  diseased  animals  were 
forbidden.  The  Paris  municipality  of  1793  enjoined  the  farmers 
to  give  their  cows  healthy  food.  Coloring  and  dilution  of  milk 
were  strictly  forbidden,  and  in  1792  they  knew  in  France  how  to 
punish  transgressors. 

74 


HISTORY    OF    PEDIATRICS 

chemical  formulae,  there  prevails  the  opinion  that  a  baby 
deprived  of  mother's  milk  may  just  as  readily  be 
brought  up  on  cow's  milk;  that  is  easily  disproved.  In 
Berlin  they  found  that  amongst  the  cow's-milk-fed  babies 
under  a  year  the  mortality  was  six  times  as  great  as 
amongst  breast-fed  infants.  Our  own  great  cities  gave 
us  similar,  or  slightly  smaller,  proportions,  until  the 
excessive  mortality  of  the  very  young  was  somewhat 
reduced  by  the  care  bestowed  on  the  milk,  introduced 
both  into  our  palaces  and  tenements.  Milk  was  exam- 
ined for  bacteria,  cleanliness,  and  chemical  reaction.  It 
was  sterilized,  pasteurized,  modified,  cooled,  but  no 
cow's  milk  was  ever  under  the  laws  of  nature  changed 
into  human  milk,  and  with  better  milk  than  the  city  of 
New  York  ever  had,  its  infant  mortality  was  greater 
this  summer  than  it  has  been  in  many  years. 

That  hundreds  of  thousands  of  the  newly-born  and 
small  infants  perish  every  year  on  account  of  the 
absence  of  their  natural  food  is  a  fact  which  is  known 
and  which  should  not  exist.  Why  do  we  kill  those 
babies  or  allow  them  to  be  killed.''  Why  is  it  that  they 
have  no  breast  milk?  A  large  number  of  women  work 
in  fields,  still  more  in  factories.  That  is  why  their 
infants  cannot  be  nursed,  are  farmed  out,  fed  artificially, 
with  care  or  without  it,  and  die.  It  is  the  mis-rule  pre- 
vailing in  our  social  conditions  which  compels  them  to 
withhold  milk  from  the  infant  while  they  are  working 
for  what  is  called  bread  for  themselves  and  their  fam- 
ilies. Many  of  these  women,  it  is  true,  would  not  have 
been-  able  to  nurse  their  newly-born,  for  their  own 
physical  condition  was  always  incompetent.  The  same 
may  be  said  of  women  in  all  walks  of  life.  Insufficient 
food,  hard  work,  care,  hereditary  debility  and  disease, 
tuberculosis,  alcoholism  of  the  woman's  own  father, 
modified  syphilis  or  nervous  diseases  in  the  family — 
aye,  the  inability  of  her  own  mother  to  nurse  her 
babies,  are  ever  so  many  causes  why  the  mother's  foun- 
tain should  run  dry.  Statistics  from  large  obstetrical 
institutions  (Hegar)  prove  that  only  about  50^  of  women 
are   capable  of  nursing  their  offspring  for  merely  a   few 

75 


DR.    JACOBI'S    WORKS 

weeks.  In  the  presence  of  such  facts  what  are  we  to  say 
of  the  refusal  of  well-situated  and  physically  competent 
women  to  mirse  their  infants  ?  I  do  not  speak  of  the 
"  400,"  I  mean  the  400,000  who  prefer  their  ease  to  their 
duty,  their  social  functions  to  their  maternal  obligations, 
who  hire  strangers  to  nurse  their  babies,  or  worse  yet, 
who  make-believe  they  believe  the  claims  of  the  infant 
food  manufacturers,  or  are  tempted  by  their  own  physi- 
cians to  believe  that  cow's  milk  casein  and  cow's  milk 
fat  may  be  changed  into  woman's  casein  and  fat,  that 
chemistry  is  physiology,  that  the  live  stomach  is  like  a 
dead  laboratory  bottle,  that  the  warmth  of  the  human 
bosom  and  that  of  a  nursing  flask  are  identical,  and  that 
cow's  milk  is  like  human  milk  when  it  carries  the 
tradesmark  "  Certified,"  or  "  Modified."  Physiological 
chemistry  itself  teaches  that  the  phosphorus  combina- 
tions in  woman's  milk  in  the  shape  of  nuclein  and 
lecithin  are  not  contained  irf  cow's  milk,  and  that  the 
large  amounts  of  potassium  and  sodium  salts  contained 
in  cow's  milk  are  dead  weights  rather  than  nutrients, 
and  particularly  the  large  amount  of  calcium  phosphate 
occurs  in  a  chemical,  not  in  a  physiological,  combina- 
tion. But  lately,  by  no  means  the  first  time,  Schloss- 
mann and  Muro  (Miinch.  med.  Woch.,  1903,  No.  14), 
have  again  proved  that  the  albuminoids  of  woman's 
and  cow's  milk  are  essentially  diiferent,  both  in  their 
lactalbumin  and  the  globulin,  and  Escherich  and  Marfan, 
that  every  milk  has   its   own   enzymes. 

The  quantitative  and  many  of  the  qualitative  differ- 
ences of  cows'  and  humarr  milk  have  been  known  a  long 
time.  No  addition  or  abstraction  of  salts,  no  addition 
of  cow's  fat  will  ever  change  one  into  the  other.  But  it 
appears  that  every  new  doctor  and  every  new  author 
begins  his  own  era.  There  is  for  most  of  modern  writers 
no  such  thing  as  the  history  of  medicine  or  of  a  specialty^ 
or  respect  of  fathers  or  brothers.  In  modern  books  and 
essays  you  meet  with  footnotes  and  quotations  of  the 
productions  of  yesterday  that  look  so  erudite,  but  also 
with  the  new  discoveries  of  old  knowledge  which  you 
would    recognize    if    the    quotation    marks    had    not    been 

76 


HISTORY    OF    PEDIATRICS 

forgotten  by  accident.  So  it  has  happened  that  many 
learn  for  the  twentieth  time  that  the  knowledge  of  the 
minimum  amount  of  required  food  is  a  wholesome 
thing,  that  the  amount  of  animal  fat  in  infant  food  is 
easily  overstepped,  that  we  have  discovered  that  the 
Dutch  had  a  clever  notion  when  they  fed  babies  on 
buttermilk  with  reduced  fat;  we  are  even  beginning  to 
learn  what  our  old  forefathers  practiced  a  hundred  years 
ago,  and  physiologists  taught  a  third  of  a  century  ago — 
namely,  that  the  newly-born  and  the  very  young  infant 
not  only  tolerate  small  quantities  of  cereals  but  that  they 
improve  on  it.  Indeed,  the  names  of  Schiller,  Korowiir, 
and  Zweifel  have  been  rediscovered.  We  have  also 
learned — just  lately,  it  appears — what  was  always 
known,  that  morning  and  night,  idleness  and  work, 
health  and  illness,  while  altering  the  chemical  compo- 
sition of  woman's  milk  do  not  necessarily  affect  its 
wholesome  character.  We  are  beginning  to  learn  that 
it  is  impossible  to  feed  a  baby  on  fanatical  chemical 
formulae,  for  they  are  not  prescribed  by  Nature,  which 
allows  latitude  within  certain  limits.  We  are  even 
beginning  to  learn  that  if  that  were  not  so  there  would 
be  no  artificially  fed  babies  alive,  and  possibly  very 
few  participants  in  the  St.  Louis  Congress  of  Arts  and 
Sciences. 

The  inability  or  reluctance  of  women  to  nurse  their 
own  infants  is  a  grave  matter.  From  a  physical,  moral, 
and  socio-political  point  of  view  there  is  only  one  calam- 
ity still  graver,  that  is  to  refuse  to  have  children  at  all. 
It  undermines  the  health  of  women,  makes  family  life  a 
commercial  institute  or  a  desert,  depopulates  the  child 
world,  reduces  original  Americans  to  a  small  minority, 
and  leaves  the  creation  of  the  future  America  in  the 
hands  of  twentieth  century  foreigners.  The  human 
society  of  the  future  will  have  to  see  to  it  that  no  pov- 
erty, no  cruel  labor  law,  no  accident,  no  luxurious  indo- 
lence, must  interfere  with  the  nursing  of  infants.  I 
believe  in  the  perfectibility  of  the  physical  and  moral 
conditions  of  the  human  race.  That  is  why  I  trust  that 
society  will  find  means   to  compel  able-bodied  women   to 

77 


DR.    JACOBI'S    WORKS 

rrurse  their  own  infants.  Infants  are  the  future  citizens 
of  the  republic.  Let  the  republic  see  that  no  harm 
accrues  from  the  incompetence  or  unwillingness  to  nurse. 
Antiquity  did  not  know  of  artificial  infant  feeding.  The 
first  information  of  its  introduction  is  dated  about  1500. 
Turks,  Arabs,  Armenians,  and  Kurds  know  of  no  arti- 
ficial feeding  to-day.  It  takes  modern  civilization  to 
expose  babies  to  disease  and  extinction.  I  know  of  no 
political  or  social  question  of  greater  urgency  than  that 
of  the  prevention  of  the  wholesale  murder  of  our  infants 
caused  by  the  withholding  of  proper  nutriment.  May 
nobody,  however,  feel  that  all  is  accomplished  when  an 
infant  has  finally  completed  his  12  months.  Society 
and  family  owe  more  than  life — they  owe  good  health, 
vital  resistance,  and  security  against  life-long  invalidism. 

But  even  willing  mothers  may  have  no  milk.  We 
require  a  stronger,  healthier  race,  and  one  that  physic- 
ally is  not  on  the  down  grade.  The  nursing  question  is 
a  social  and  economic  problem  like  so  many  others,  like 
the  childbearing  question,  that  confront  modern  civiliza- 
tion. 

We  are  building  hospitals  for  the  sick  of  all  classes, 
and  insist  upon  their  being  superior  to  the  best  private 
residences;  asylums  for  the  insane,  neuropathies,  and 
drunkards;  nurseries  and  schools  for  epileptics,  cretins, 
and  idiots ;  refuges  for  the  dying  consumptives ;  and 
sanatoria  for  incipient  tuberculosis.  We  are  bent  upon 
curing  and  upon  preventing.  Do  we  not  begin  at  the 
wrong  end?  We  allow  consumptives  and  epileptics  to 
marry  and  to  propagate  their  own  curse.  We  have  no 
punishment  for  the  syphilitic  and  the  gonorrhoeic  who 
ruins  a  woman's  life  and  impairs  the  human  race. 
Man,  however,  must  see  that  his  kind  shall  not  suffer. 
One-half  of  us  should  not  be  destined  to  watch,  and 
nurse,  and  support  the  other  half.  Human  society  and 
the  State  have  to  protect  themselves  by  looking  out  for 
a  healthy,  uncontaminated  progeny.  Laws  are  required 
to  accomplish  this;  such  laws  as  will  be  hated  by  the 
epileptic,  consumptive,  the  syphilitic,  and  the  vicious. 
No   laws   ever   suited   the   degenerates   against  whom   they 

78 


HISTORY    OF    PEDIATRICS 

were  passed,  and  it  is  unfortunate  that  while  health  and 
virtue  are  as  a  rule  not  contagious,  disease  and  vice  are 
so  to  a  high  degree. 

Modern  Therapeutics,  both  hygienic  and  medicinal, 
has  gained  much  by  the  close  observation  of  what  is 
permitted  or  indicated  or  required  in  early  age.  Since 
it  has  become  more  humane  (remember  it  is  hardly  a 
century  since  Pinel  took  the  chains  off  the  insane  in 
their  dungeons,  and  not  more  than  half  a  century  since 
I  was  taught  to  carry  my  venesection  lancet  in  my  vest 
pocket  for  ready  use)  and  more  scientific,  so  that  what- 
ever is  outside  of  strict  biologic  methods  is  no  longer 
"  a  system,"  but  downright  quackery — the  terrible 
increase  of  the  latter  as  a  world-plague  is  deemed  by 
rational  practitioners  and  the  sensible  public  an"  appal- 
ling anachronism.  It  appears  that  the  States  of  the 
Union  are  most  anxious  (and  have  been  partially  suc- 
cessful) to  rid  themselves  of  it,  while  some  at  least  of  the 
nations  of  Europe  are  greater  sufferers  than  we.  Accord- 
ing to  the  latest  statistics,  there  is  one  quack  to  every 
physician  in  Bavaria  and  Saxony;  ten  quacks  in  Berlin, 
with  its  emperor  and  other  accomplishments,  to  every 
forty-six  physicians.  Its  general  population  has  increased 
since  1879  by  61%;  the  number  of  physicians,  1702%; 
that  of  the  quacks,   l600<^ 

One  of  the  main  indications  in  infant  therapeutics  is 
to  fight  anemia,  which  is  a  constant  danger  in  the  dis- 
eases of  the  young,  for  the  amount  of  blood  at  that  age 
is  only  one-nineteenth  of  the  whole  body  weight,  while 
in  the  adult  it  is  one-thirteenth.  The  newly-born  is 
particularly  exposed  to  an  acute  anemia.  His  blood 
weighs  from  200  to  250  grammes.  It  is  overloaded 
with  haemoglobin  which  is  rapidly  eliminated,  together 
with  the  original  excess  of  iron.  This  lively  metabolism 
renders  the  infant  very  amenable  to  the  influence  of 
bacteria,  and  the  large  number  of  acute,  sub-acute,  or 
chronic  cases  of  sepsis  is  the  result.  Besides,  the  prin- 
cipal normal  food  is  milk,  which  contains  but  little  iron. 
That  is  why  pediatrics  is  most  apt  to  inculcate  the  les- 
sons of  appropriate  posture,  so  as  not  to  render  the  brain 

79 


DR.    JACOBI'S    WORKS 

suddenly  anemic,  and  of  proper  feeding  and  of  timely 
stimulation  before  collapse  tells  us  we  are  too  late,  and 
the  dangers  of  inconsiderate  depletion.  The  experience 
accumulated  in  pediatric  practice  has  taught  general 
medicine  to  use  small  doses  only  of  potassic  chlorate; 
large  doses  of  strychnine  and  alcohol  in  sepsis,  of 
mercuric  bichloride  in  croupous  inflammations,  of  heart 
stimulants,  such  as  digitalis,  when  a  speedy  effect  is 
wanted,  of  arsenic  in  nervous  diseases,  of  potassic  iodide 
in  meningitis;  it  has  warned  practical  men  of  the 
dangers  of  chloroform  in  status  lymphaticus  ;•''  it  has 
modified  hydrotherapeutic  and  balneological  practice, 
and  the  theories  of  hardening  and  strengthening  accord- 
ing to  periods  of  life,  and  to  the  conditions  of  previous 
general  health. 

The  appreciation  of  electricity  as  a  remedy  has  been 
enhanced  by  obstetricians,  pediatrists  arrd  general  prac- 
titioners. It  is  but  lately  that  we  have  been  told  (P. 
Strassmann,  Samml.  Klin.  Vortr.,  1903,  No.  353)  that  a 
newly-born  and  an  infant  up  to  the  third  week  are  per- 
fectly insensible  to  very  strong  electrical  currents.  The 
incompetency  of  mere  experimental  work,  not  corrected 
or  guided  by  practice,  cannot  find  a  better  illustration, 
for  there  is  no  more  powerful  remedy  for  asphyxia  and 
atelectasis  than  the  cautious  use  of  the  interrupted  or  of 
the  broken   galvanic  current. 

The  domain  of  preventive  therapeutics  expands  with 
the  increased  knowledge  of  the  causes  of  disease.  That 
is  why  immunizing,  like  curative  serums,  will  play  a 
more  beneficent  part  from  year  to  year,  and  why  the 
healthy  condition  of  the  mucous  membrane  of  the  nose, 
mouth,  and  pharynx,  which  I  have  been  advising  these 
forty   years   as   a    prevention    of   diphtheria,   has   assumed 

5  In  the  meeting  of  the  Society  for  the  Study  of  Disease  in 
Children,  May  27,  1904,  Mr.  Thompson  Walker  alluded  to  the 
collection  of  ten  cases  with  status  lymphaticus  in  which  death 
had  occurred  at  the  commencement  of  chloroform  administration, 
or  during  it,  or  immediately  after  the  operation.  In  addition  to 
the  usual  changes,  a  hyperplasia  of  the  arteries  had  been  noted, 
leading  to  narrowing  of  the  lumen. 

80 


HISTORY    OF    PEDIATRICS 

importance  in  the  armamentarium  of  protection  against 
all   sorts   of   infectious   diseases. 

Amongst  the  probabilities  of  our  therapeutical  future 
I  also  count  the  prevention  of  congenital  malformations, 
which,  as  has  been  shown,  are  more  numerous  than  is 
generally  known  or  presumed,  and  often  the  result  of 
intrauterine  inflammation.  In  a  recent  publication  F. 
von  Winckel  (Samml.  Klin.  Vortr.,  1904,  No.  373) 
emphasizes  the  fact  that  the  general  practitioner  or  the 
pathologic  anatomist  sees  only  a  small  number,  that 
indeed  the  majority  are  buried  out  of  sight,  or  are  pre- 
served in  the  specimen  jars  of  the  obstetrician.  The 
known  number  of  malformations  compared  with  that  of 
the  normal  newly-born  varies  from  one  to  thirty-six,  to 
one  to  one  himdred  and  two  or  more.  They  are  met 
with  in  relatively  large  numbers  on  the  head,  face  and 
neck — altogether  in  53.2^  of  all  the  190  cases  of  mal- 
formation observed  in  Munich  during  twenty  years.  A 
number  of  them  is  the  result  of  heredity,  of  syphilis 
or  other  influences.  How  many  are  or  may  be  the 
result  of  consanguineous  marriages  will  have  to  be  learned. 
In  all  such  cases  the  treatment  of  the  parents  or  the 
prohibition  of  injurious  marriages  will  have  to  be  insisted 
upon.  The  number  of  those  recognized  as  due  to  amniotic 
adhesions  or  bands  is  growing  from  year  to  year.  Kum- 
mel  could  prove  that  of  178  cases,  29  were  certainly  of 
that  nature.  External  malformations  have  long  been 
ascribed  to  them;  proximal  malformations,  such  as 
auricular  appendices,  harelip,  anencephalia,  cyclopia, 
flattening  of  the  face,  anophthalmia,  hereditary  poly- 
dactylia  (Ahlfeldt  and  Zander,  Virchow's  Archiv,  1891), 
and  lymphangioma  of  the  neck,  have  been  found  to  be 
caused  by  amniotic  attachments  or  filaments.  Is  it  too 
much  to  believe  that  the  uterus,  whose  internal  changes, 
syphilitic  or  others,  are  known  to  be  very  accessible  to 
local  and  general  medication,  should  be  so  influenced  by 
previous  treatment  that  malformations  and  foetal  deaths 
will  become  less  and  less  frequent? 

The  problem  of  the  health  and  hygiene  mainly  of  the 
older    child    refers    to    more    than    its    food.     The    school 

81 


DR.    JACOBI'S    WORKS 

question  is  in  the  foreground  of  the  study  of  sanitarians, 
health  departments,  physicians,  and  pedagogues.  Its 
importance  is  best  illustrated  by  the  large  convention 
which  was  organized  in  Stuttgart,  April,  1904,  as  an 
International  Congress  for  School  Hygiene.  Pediatrists, 
pedagogues,  and  statesmen  formulated  their  demands 
and  mapped  out  future  discussions.  Rational  pediatrics 
would  consider  the  following  questions :  Is  it  reason- 
able to  have  the  same  rule  and  the  same  daily  sessions 
for  children  of  eight  and  perhaps  of  fifteen  years,  and  for 
adolescents?  Certainly  not.  The  younger  the  child  the 
shorter  should  be  the  session,  the  longer  and  more  fre- 
quent the  recesses.  There  should  be  no  lessons  in  the 
afternoon,  or  only  mechanical  occupations,  such  as  copy- 
ing, or  light  gymnastics.  There  should  be  no  home 
lessons. 

The  problem  of  overburdening  was  carefully  con- 
sidered by  Lorinser  in  1836,  and  by  many  since.  It  deals 
with  the  number  of  subjects  taught,  the  strictness  and 
frequency  of  official  examinations,  and  should  consider 
the  overcrowding  of  school  rooms.  We  should  try  to 
answer  the  question  whether  neuroses  are  more  the 
result  of  faulty  schooling  or  of  original  debility,  heredity, 
underfeeding,  lack  of  sleep,  bad  domestic  conditions,  or 
all  these  combined.  In  Berlin  schools  they  have  begun 
to  feed  the  hungry  ones  regularly  with  milk  and  bread. 
No  compulsory  education  will  educate  the  starving.  The 
child  that  showed  his  first  symptom  of  nervousness 
when  a  nursling,  the  child  with  pavor  nocturnus,  or 
that  gets  up  tired  in  the  morning,  or  suffers  from  motor 
hyperaesthesia,  pointing  or  amounting  to  chorea,  unless 
relieved  instead  of  being  punished  by  an  uninformed  or 
misanthropic  or  hysterical  teacher,  gets  old  or  breaks 
down  before  the  termination  of  the  school  term  or  of 
school  age.  There  should  be  separate  classes  for  the 
feeble,  for  those  who  are  mentally  strong,  or  weak,  or  of 
medium  capacity.  All  of  such  questions  belong  to  the 
domain  of  the  child's  physician,  the  physician  in  gen- 
eral. The  office  of  school  physician  is  relatively  new. 
Whatever    we    have    done    in    establishing    it    in    America 

82 


HISTORY    OF    PEDIATRICS 

has  been  preceded  by  countries  to  which  we  are  not  in 
the  habit  of  looking  for  our  models.  Bulgaria  and 
Hungary  have  no  schools  without  physicians.  On  the 
other  hand,  Vienna  has  none  for  its  200,000  school 
children.  It  is  reported  that  the  aldermen  refused  to 
appoint  one.  One  of  them  objected  for  the  reason  that 
the  doctor  might  be  tempted  to  examine  the  Vienna 
lassies  too  closely.  His  business  would  be,  and  is,  to 
look  out  for  the  healthfulness  of  the  school  building,  its 
lighting,  M'arming,  cleanliness,  the  cleanliness  of  the 
children  and  their  health,  and  that  of  the  teachers.  A 
tubercular  teacher  is  a  greater  danger  to  the  children 
than  these,  who  rarely  expectorate,  to  each  other.  He 
would  take  cognizance  of  the  first  symptoms  of  infec- 
tious diseases,  examine  eyes,  ears,  and  teeth,  and  inquire 
into  chronic  constitutional  diseases,  such  as  rachitis  and 
scrofula  in  the  youngest  pupils.  He  might  undertake 
anthropometrical  measurements  and  benefit  science 
while  aiding  his  wards.  He  would  be  helped  in  all  these 
endeavors  by  the  teachers  who  must  learn  to  pride 
themselves  on  the  robust  health  of  their  pupils,  as  they 
now  look  for  the  accumulation  of  knowledge  which  may 
be  exhibited  in  public  examinations. 

They  would  soon  learn  what  Christopher  demon- 
strated, that  physical  development,  greater  weight,  and 
larger  breathing  capacity,  correspond  with  increased 
mental  power,  joining  to  this  the  advice  that  a  physical 
factor  as  well  as  the  intellectual  one,  now  entirely  relied 
upon,  should  be  introduced  in  the  grading  of  pupils. 
(Charles  F.  Gardiner  and  H.  W.  Hoagland,  Growth  and 
Development  of  Children  in  Colorado. — Trans.  Am. 
Climatological    Ass'n,    1903.) 

Our  knowledge  of  the  physiology  and  pathology  of 
the  nervous  system  of  all  ages  would  be  defective  with- 
out lessons  derived  from  the  foetus  and  infant.  Amongst 
the  newh^-born  we  have  often  to  deal  with  arrests  of 
development,  such  as  microcephalus,  or  with  that 
form  of  foetal  meningitis  or  of  syphilitic  alterations  of 
blood-vessels  which  may  terminate  in  chronic  hydro- 
cephalus.      When    the    insufficient    development    of    reflex 

83 


DR.    JACOBI'S    WORKS 

action  in  the  newly-born  up  to  the  fifth  or  sixth  week 
has  passed,  the  very  slow  development  of  inhibition 
during  the  first  half  year  or  more,  together  with  the 
rapid  increase  of  motor  and  sensitive  irritability,  explains 
the  frequency  of  eclampsia  and  other  forms  of  convul- 
sions. Many  of  them  require,  however,  an  additional 
disposition,  which  is  afforded  either  by  the  normal  rapid 
development  of  the  brain,  or  the  abnormal  hypermia 
of  rachitis.  The  last  25  years  have  increased  our 
knowledge  considerably  in  many  directions.  Congenital 
or  premature,  complete  or  partial,  ossification  of  the 
cranial  sutures  lead  mechanically  to  idiocy,  or  paralysis, 
or  epilepsy;  it  is  a  consolation,  however,  to  know  that 
the  victims  of  surgical  zeal  are  getting  less  in  number 
since  operators  have  consented  to  fear  death  on  the 
operating  table,  and  thoughtful  surgeons  have  come  to 
the  conclusion  to  leave  bad  enough  alone.  In  the  very 
young  the  fragility  of  the  blood-vessels,  the  lack  of  coagu- 
lability of  the  blood,  the  large  size  of  the  carotid  and 
vertebral  arteries,  the  frequency  of  trauma  during 
labor  and  after  birth,  the  vulnerability  of  the  ear  and 
scalp,  contribute  to  the  frequency  of  nervous  diseases, 
which  before  the  fifth  year  amounts  to  87^  of  all 
the  cases  of  sickness.  Rapid  exhaustion  leads  to 
intracranial  emaciation  and  thrombosis,  the  so-called 
hydroencephaloid  of  gastro-enteritis.  The  large  size  and 
number  of  the  lymph  vessels  of  the  nasal  and  pharyngeal 
cavities  facilitate  the  invasion  into  the  nerve  centers  of 
infections  which  show  themselves  as  tubercular  menin- 
gitis, cerebro-spinal  meningitis,  and  polio-encephalitis, 
or  more  so,  poliomyelitis,  and  as  chorea  of  so-called 
rheumatic  —  mostly  streptococci  —  origin.  Nose  and 
throat  specialists,  as  well  as  anatomists,  have  con- 
tributed to  our  knowledge  on  these  points — another  proof 
of  the  intimate  dependency  of  all  parts  of  medicine  upon 
one  another.  Now  all  these  conditions  are  not 
limited  to  early  life,  but  their  numerical  preponder- 
ance at  that  time  is  so  great  that  it  is  easy  to  understand 
that  general  nosology  could  not  advance  without  the 
overwhelming     number     of     well-marked     cases     amongst 

84 


HISTORY    OF    PEDIATRICS 

children.  Amongst  them  are  the  very  numerous  cases 
of  epilepsy.  They  escape  statistical  accuracy,  for  many 
an  epileptic  infant  or  child  dies  before  his  condition  is 
observed,  or  diagnosticated;  a  great  many  cases  of 
petit  mal,  vertigo,  dreamlike  states  and  somnambulism, 
fainting,  habit-chorea,  truancy,  imbecility,  incompetency, 
or  occasionally  wild  attacks  of  mania,  or  the  per- 
versity of  incendiarism,  or  in  older  children  religious 
delirium,  even  hysteric  spells,  are  overlooked  or  perhaps 
noticed  or  suspected  by  nobody  but  the  family  physi- 
cian ;  or,  in  the  cases  of  the  million  poor,  by  nobody. 
They  are  cared  for  or  neglected  at  home,  and  the  seizure 
is  taken  to  be  an  eclamptic  attack  due  to  bowels,  worms, 
colds,  and  teeth,  exactly  like  three  hundred  years  ago. 

Of  equal  importance  in  this  disease  to  the  pediatrist, 
the  pedagogue,  the  psychiatrist,  the  judge,  the  states- 
man, no  matter  whether  in  office  or  a  thoughtful  citizen, 
is  the  influence  of  heredity.  The  old  figures  of  Eche- 
verria,  which  have  been  substantiated  by  a  great  many 
observers,  tell  the  whole  story.  One  hundred  and  thirty- 
six  epileptics  had  553  children.  Of  these,  309  remained 
alive;  78  (25^)  were  epileptic;  how  many  of  the  231 
that  died  had  some  form  of  epilepsy  or  would  have 
exhibited  it  nobody  can  tell.  He  observed  a  dozen  cases 
in  one  family.  While  in  his  opinion  29.72%  showed  a 
direct  inheritance  from  epileptic  parents,  Gowers  has  a 
percentage  of  35,  and  Spratling,  who  has  lived  among 
epileptics  nearly  a  dozen  years,  66. 

Epilepsy  is  acknowledged  to  be  one  of  the  causes  of 
imbecility,  or  genuine  idiocy.  In  very  many  instances 
it  should  be  considered  as  the  co-ordinate  result  of  corr- 
genital  or  acquired  changes  in  the  skull,  the  brain,  and 
its  meninges,  and  particularly  the  cortex.  In  a  single 
idiot  institution,  that  of  Langenhagen,  15^  to  18^?^  of 
the  395 — -668  inmates  were  epileptic;  in  another,  Dalldorf. 
18.5^  to  24.3^  of  167—344;  in  a  third,  Idstein,  36%  of 
101  (Binswanger,  in  Nothnagel,  Syst.  Path.  u.  Ther.,  Vol. 
xii,    1,310). 

Its  main  causes  are  central.  External  irritations, 
worms,    calculi,    genital    or    nasal    reflexes,    may    be    occa- 

85 


DR.    JACOBI'S    WORKS 

sional  proximate  causes.  But  cauterization  of  the  nares, 
and  still  more,  circumcision,  and  clitoridectomy  prove 
more  the  helplessness  or  recklessness  of  the  attendant 
than  the  possibility  of  a  cure.  The  individual  cases  of 
recovery  by  the  removal  of  clots,  bones,  or  tumors,  are 
great  and  comforting  results,  but  if  epilepsy  and  its  rela- 
tions are  ever  to  disappear,  it  is  not  the  knife  of  the 
surgeon  but  the  apparatus  of  human  foresight  and  justice 
that  will  accomplish  it.  Most  of  the  causes  of  epilepsy 
are  preventable.  To  that  class  belongs  syphilis  and 
alcoholism  in  various  generations,  rachitis,  tuberculosis 
and  scrofula,  many  cases  of  encephalo-meningitis,  and 
most  cases  of  otitis.  A  question  is  attributed  to  a  royal 
layman,  "If  preventable,  why  are  they  not  prevented?" 
If  there  is  a  proof  of  what  Socrates  and  Kant  said, 
namely,  that  statesmanship  cannot  thrive  without  the 
physician,  it  is  contained  in  the  necessities  of  epilepsy. 
Prevention,  preventives  and  hygienic,  medicinal,  and 
surgical  aids  have  to  be  invoked,  unfortunately  with 
slim  results   so   far. 

The  influence  of  hereditary  syphilis  on  tJie  diseases 
of  the  nervous  system  has  been  studied  these  20  years, 
both  by  neurologists  and  pediatrists.  Its  results  are  either 
direct — that  means  characteristically  syphilitic — or  meta- 
syphilitic — ^that  means  merely  degenerative.  Hoffmann 
cured  a  case  of  syphilitic  epilepsy  in  a  girl  of  nine  years 
in  1712.  Plenk  describes  convulsions  and  other  nervous 
symptoms  depending  on  hereditary  syphilis,  and  Nil 
Rosen  de  Rosenstein  describes  the  same  in  1781.  The 
literature  of  the  later  part  of  the  eighteenth,  and  of  the 
first  half  of  the  nineteenth  century  is  silent  on  that  sub- 
ject, though  the  cases  of  affections  of  the  nervous  system 
depending  on  hereditary  syphilis  are  very  frequent 
(thirteen  per  cent,  of  all  the  cases,  according  to  Rumpf 
die  Syph.  Erk.  d.  Nervensystems,  1889).  Jullien  (Arch. 
Gen.,  1901)  reports  260  pregnancies  in  43  syphilitic 
matrimonies.  Of  the  children,  162.  remained  alive. 
Half  of  them  had  convulsions  or  symptoms  of  meningitis. 

According  to  Nonne  (Die  Syph.  d.  Nervens.,  1902) 
hereditary    syphilis    differs    from    the    acquired    form    in 

86 


HISTORY   OF   PEDIATRICS 

this — that  several  parts  of  the  nervous  system  are  affected 
simultaneously;  and  that  arteritis,  meningitis,  gum- 
mata,  and  simple  sclerosis  occur  in  combination.  Simple 
cerebral  meningitis  and  apoplexies  are  very  rare. 
Encephalitis  is  more  frequent.  Probably  spinal  dis- 
eases are  more  frequent,  according  to  Gilles  de  la  Tou- 
rette,  Gasne,  Sachs,  and  others.  Tabes  dorsalis  is  not 
frequent,  but  may  rather  depend  on  an  atavistic  syphilitic 
basis;  for  altogether  the  nerve  syphilis  of  the  second 
previous  generation  as  a  cause  of  disease  in  the  young  is 
not  very  rare.      (E.  Finger,  W.  klin.  Woch.,  13,  1900.) 

What  we  call  neuroses  are  not  infrequent  in  infants  and 
children.  Neuralgias  are  not  so  common  as  in  the  adult, 
but  would  be  more  frequently  found  if  sought  for.  Even 
adipositas  dolorosa  has  been  observed  in  childhood. 
Hysteria  is  by  no  means  rare,  and  its  mono-symptomatic 
character,  so  peculiar  to  early  age,  adds  to  its  nosological 
importance.  Its  early  appearance  is  of  grave  import.  Its 
often  hereditary  origin  makes  it  a  serious  problem, 
under-alimentation  or  ill-nutrition,  rachitis  and  scrofula, 
frequently  connected  with  and  underlying  it,  may  make 
it  dangerous  and  a  fit  subject  for  the  study  of  educators, 
psychologists,  judges,  and  all  those  whose  direct  office  it 
is  to  study  social  and  socialistic  problems.  Hysteria  is 
not  quite  unknown  amongst  males,  though  the  large 
majority  are  females. 

Some  of  the  vaso-motor  and  trophic  disturbances  are 
less,  others  more  frequent,  in  the  young  than  in  the 
adult.  Amongst  129  cases  of  akroparaesthesia  there  is 
only  one  of  Frankl  Hochwart  in  a  girl  of  12  years,  and 
one  of  Cassirer  in  a  girl  of  16.  Sclerodermia  is  met  with 
mostly  in  mature  life,  but  the  cases  of  Neumann  at  13 
days,  and  those  of  Cruse,  Herxheimer,  and  of  Haushalter 
and  Spielmarm,  who  observed  two  cases  in  one  family, 
all  of  them  when  the  infants  were  only  a  few  weeks  old, 
prove  that  the  same  influences  which  are  at  work  in 
advanced  age,  namely,  hereditary  disposition,  neu- 
ropathic family  influence,  low  general  nutrition,  colds, 
trauma,  and  so  on,  may  play  their  role  in  infant  life. 
Nor     are     infant     erythromelalgias     numerous.         Henoch 

87 


DR.    JACOBI'S    WORKS 

saw  one  in  a  teething  infant,  Baginsky  in  a  boy  of  10, 
Heimann  one  in  a  girl  of  13,  Graves  one  in  a  girl  of  16; 
that  means  three  or  four  eases  below  13  or  l(j  years  of 
age,  out  of  a  number  of  65  collected  by  Cassirer  in 
his  monograph.  (Die  Vasomotorisch-trophischen  Neu- 
rosen,  Berlin,  1901.)  In  half  a  century  I  have  seen  but 
one  that  occurred  in  early  age,  namely,  in  a  boy  of  12, 
who  got  well  with  the  loss  of  two  toes.  On  the  other 
hand,  the  symmetrical  gangrene  of  Raynaud  and  acute 
circumscribed  oedema  of  Milton  and  Quincke,  1882, 
treated  of  by  Collins  in  1892,  are  by  no  means  relatively 
rare  in  infancy  and  childhood.  There  are  a  few  cases  of 
the  former  that  occurred  in  the  newly-born.  Two  I 
have  seen  myself.  There  are  those  which  have  been 
observed  at  6  months  (Friedel),  9  months  (De  France), 
at  15  months  (Bjering),  at  18  months  (Dick).  In  the 
year  1889  Morgan  collected  93  cases,  13  of  which  occurred 
from  the  second  to  the  fifth,  11  between  the  fifth  and 
tenth,  and  15  between  the  tenth  and  twentieth  years. 
Amongst  the  168  cases  collected  by  Cassirer,  20  occurred 
under  the  fifth,  8  between  the  fifth  and  tenth,  and  25 
between  the  tenth  and  twentieth  years  of  life.  Like 
most  nervous  diseases,  these  cases  had  either  congenital 
or  acquired  causes,  amongst  which  a  general  neuropathic 
constitution,  and  the  hereditary  influence  of  alcohol, 
chlorosis,  and  anemia  are  considered  prominent.  Of 
acute  circumscribed  oedema,  28  cases  are  found  below 
nine  years  of  age  in  Cassirer 's  collection  of  l60  cases,  one 
of  which  at  the  age  of  one  and  a  half  months  is  reported 
by  Crozer  Griffith,  one  at  three  months  by  Dinckelacker. 
Again  hereditary  influence  is  found  powerful.  Osier 
could  trace  the  disease  through  five  generations. 

The  connection  of  pediatrics  with  psychiatry  is  very 
intimate.  Insane  children  are  much  more  numerous 
than  the  statistics  of  lunatic  asylums  would  appear  to 
prove,  for  there  are,  for  obvious  reasons,  but  few  insane 
children  in  general  institutions.  It  is  only  those  cases 
which  become  absolutely  unmanageable  at  home  that 
are  entrusted  to  or  forced  upon  an  asylum.  The  example 
of    the    French,    who    more    than    50    years    ago    had    a 

88 


HISTORY    OF    PEDIATRICS 

division  in  the  Bicetre  for  mentally  disturbed  children, 
has  seldom  or  not  at  all  been  imitated.  Thus  it  happens 
that  though  not  even  a  minority  of  the  cases  of  idiocy 
become  known,  its  statistics  is  more  readily  obtained  than 
that  of  dementia  of  early  life.  Some  of  its  physical 
causes  or  accompaniments  have  been  mentioned — 
asphyxia  with  its  consequences,  ossification  and  asymmet- 
rical shape  of  the  cranium,  accidents  during  infancy 
and  childhood,  neuroses  that  may  be  the  beginning  or 
proximate  causes  of  graver  trouble.  Infectious  diseases 
play  an  important  part  in  the  etiology  of  intellectual 
disorders.  Althaus  collected  400  such  cases.  They 
were  mainly,  influenza  113,  rheumatism  96,  typhoid 
fever  87,  pneumonia  43,  variola  41,  cholera  19,  scarlatina 
16,  erysipelas  11.  In  most  of  the  cases  there  were 
predisposing  elements,  such  as  heredity  and  previous 
diseases,  or  over-exertion  of  long  duration.  The  over- 
worked brains  of  school  children  were  complained  of  as 
adjuvant  causes  of  lunacy  by  Peter  Frank  as  early  as 
1804.  We  are  as  badly  oif  or  worse,  a  hundred  years 
later. 

There  is  one  ailment,  however,  that  appears  to  hurt 
children  less  than  it  does  adolescents  or  adults,  that  is 
masturbation.  There  are  those  cases,  fortunately  few, 
which  depend  on  cerebral  disease,  and  original  degen- 
eracy, but  in  the  large  majority  of  instances  mastur- 
bation, frequent  though  it  be,  has  not  in  the  very  young 
the  same  perils  that  are  attended  with  it  later  on  when 
the  differentiation  of  sex  has  been  completed  and  is 
recognized.  Babies  under  a  year,  and  children  under  8 
or  ten  will  outlive  their  unfortunate  habit,  and  do  not 
appear  to  suffer  much  from  its  influence.  Whatever 
is  said  to  the  contrary  is  the  exaggeration  of  such  as  like 
to  revel  in  horrors.  The  same  exorbitant  imagination 
is  exhibited  in  other  statements.  What  Lombroso  and 
his  followers  have  said  of  the  faulty  arrangement  of  the 
teeth,  prognathic  skulls,  retracted  nose,  short  and 
attached  lobes  of  the  auricle,  as  distinct  symptoms  of 
mental  degeneracy,  belongs  to  that  class,  and  need  not 
always    be    taken    as    the    positive    signs    of    insane   crimi- 

89 


DR.    JACOBI'S    WORKS 

nality.  There  is  so  much  poetical  exaggeration  and  word 
painting  in  them  that  Lombroso  and  also  Krafft-Ebing 
are  the  pets  of  the  prurient  lay  public.  In  its  midst 
there  must  be  many  who  are  anxious  to  believe  with 
Lombroso  that  brown  hair  and  eyes,  brachycephalic 
heads,  and  medium  size  of  the  body  characterize  the 
insane  criminal,  if  only  for  the  purpose  of  scanning  the 
hair  and  eyes  and  heads  of  their  near  friends  and  their 
mother-in-law's   relatives. 

It  is  certainly  not  true  that,  as  Lombroso  will  have 
it,  children  are  cruel,  lazy,  lying,  thievish,  just  as  little 
as  according  to  him  all  savages  are  like  carnivorous 
animals,  and  essentially  criminal,  while  others  are  con- 
vinced that  by  nature  they  are  amiable,  like  Uncas,  and 
virtuous  like  Chingacook,  and  have  been  rendered  sav- 
age only  by  the  strenuousness  of  conquering  immigrants. 
Nor  is  it  true  that  the  idiot  brain  is  merely  arrested  at  a 
stage  similar  to  anthropoid,  or  even  saurian  develop- 
ment, for  it  is  less  arrest  of  development  than  the  influ- 
ence of  embryonal  or  foetal  disease,  beside  amniotic 
anomalies  that  cause  the  irregularities  of  the  encephalon. 

Amongst  the  worst  causes  of  idiocy  is  cretinism,  both 
the  endemic,  and  the  sporadic.  Every  cretin  is  an  idiot, 
not  vice  versa.  The  first  could  be  prevented  by  State 
interference  which  would  empty  the  stricken  valleys; 
the  latter  depends  on  thyroidism,  with  or  without  a 
shortening  of  the  base  of  the  skull,  and  is  partially 
curable.  The  idiotism  of  cretinism  causes  a  fairly 
uniform  set  of  symptoms;  that  which  depends  on  other 
causes  exhibits  varieties,  though  not  so  many  as  imbe- 
cility, which,  too,  should  not  be  taken  to  be  the  result  of 
a  single  cause.  Osseous  and  cartilaginous  anomalies 
about  the  nose  are  pointed  out  by  William  Hill,  chronic 
pharyngitis  and  nasal  polypi  by  Heller,  enlarged  tonsils 
by  Kafemann  in  one-third  of  the  cases,  some  pharyngeal 
or  nasal  anomaly  in  four-fifths  by  Schmid-Monnard. 
Adenoids  are  frequently  found  as  complications.  Oper- 
ations to  meet  all  these  anomalies  have  been  performed 
with  improvement  of  the  mental  condition  in  some,  of 
the   physical   in  many  more,   mainly   when    the   anomalies 

90 


HISTORY   OF   PEDIATRICS 

were  complications  only.  But  after  all  we  should  be- 
ware of  the  belief  in  miracles  and  in  infallible  cures. 
Mainly  the  tonsils  have  been  puffed  up  to  be  the  main 
causes  of  many  human  troubles  and  their  removal  a 
panacea.  According  to  a  modern  writer  it  prevents  tu- 
berculosis, but  the  prophet  is  a  little  too  bold,  for  he 
adds  that  with  the  exception  of  himself  there  are  very 
few  able  to  accomplish  it.  Defective  or  diseased  brains 
are  frequent  in  most  conditions.  The  former  class  allows 
even  imbeciles  to  excel  in  some  ways.  In  that  class  may 
be  found  calculating  experts,  chess-players,  or  mechanical 
draughtsmen. 

Imbecile  persons  may  be  taught  sufficiently  to  prepare 
for  the  simple  duties  of  life.  There  are,  however,  many 
transitions  between  the  complete  imbecile,  the  mild  im- 
becile, and  the  merely  slow  and  dull.  That  is  why  the 
condition  is  frequently  not  appreciated.  In  his  school  the 
imbecile  child  is  slightly  or  considerably  behind  his  class, 
and  the  laughing-stock  of  the  rest.  As  he  is  intellectually 
slow,  so  he  is  morally  perverse  or  is  made  to  become  so. 
He  knows  enough  to  lie  and  libel,  to  run  away  from  school, 
and  from  truant  to  become  a  vagrant.  It  is  true  it  will 
not  do  to  declare  the  imbecile  per  se  identical  with  the 
typical  criminal,  but  as  many  of  them  are  illegitimate,  or 
of  defective  or  alcoholic  parents,  or  maltreated  at  home, 
or  diseased  and  deformed,  they  get,  by  necessity,  into  con- 
flict with  order  and  the  law.  Thompson  found  218  con- 
genital imbeciles  among  943  penitentiary  inmates.  Knecht, 
41  amongst  1,214.  When  the  imbecile  is  once  a  prisoner 
his  condition  is  not  liable  to  be  noticed  on  account  of  the 
stupefying  monotony   of   his   existence. 

What  is  more  to  be  pitied,  the  fate  of  the  immature 
or  imbecile  half-grown  child  that  naturally  acts  differ- 
ently from  the  normal,  or  the  low  condition  of  the  State 
which  instead  of  procuring  separate  .schools  for  the  half- 
witted, or  asylums,  has  nothing  to  offer  but  contumely 
and  prison  walls,  and  irrcreasing  moral  deterioration? 
There  is  the  stone  instead  of  the  bread  of  the  gospel. 

Modern  society  has  commenced,  however,  to  mend  old 
injustices.     Every  civilized  country  admits  irresponsibility 

91 


DR.    JACOBI'S    WORKS 

before  ^the  law  below  a  certain  age,  and  gradually  the 
mental  condition  of  the  criminal  is  taken  into  considera- 
tion and  made  the  subject  of  study.  But  still  thousands 
of  children  and  adolescents  are  declared  criminals  before 
being  matured.  The  establishment  of  children's  courts  is 
one  of  the  things,  imperfect  though  they  be,  that  make 
us  see  the  promised  land  from  afar.  When"  crime  will  be 
considered  an  anomaly,  either  congenital  or  acquired  in 
childhood,  a  disease;  when  society  will  cease  to  insist  upon 
committing  a  brutality  to  avenge  a  brutality;  when  self- 
protection  will  take  the  place  of  revenge,  and  asylums 
that  of  State  prisons — then  we  shall  be  a  human^  because 
humane,  society. 

CONCLUSIONS 

Pedology  is  the  science  of  the  young.  The  young  are 
the  future  makers  and  owners  of  the  world.  Their  phys- 
ical, intellectual  and  moral  condition  will  decide  whether 
the  globe  will  be  more  Cossack  or  more  Republican,  more 
criminal  or  more  righteous.  For  their  education  and  train- 
ing and  capabilities,  the  physican,  mainly  the  pediatrist, 
as  the  representative  of  medical  science  and  art,  should 
become  responsible.  Medicine  is  concerned  with  the  new 
individual  before  he  is  born,  while  he  is  being  born,  and 
after.  Heredity  and  the  health  of  the  pregnant  mother 
are  the  physician's  concern.  The  regulation  of  labor  laws, 
factory  legislation,  and  the  prohibition  of  marriages  of 
epileptics,  syphilitics,  and  criminals  are  some  of  his  pre- 
ventive measures  to  secure  a  promising  progeny.  To  him 
belongs  the  watchful  care  of  the  production  and  distribu- 
tion of  foods.  He  has  to  guard  the  school  period  from 
sanitary  and  educational  points  of  view,  for  heart  and 
muscle  and  brain  are  of  equal  value.  It  is  in  infancy 
and  childhood,  before  the  dangerous  period  of  puberty 
sets  in,  that  the  character  is  formed,  altruism  inculcated, 
or  criminality  fostered.  If  there  be  in  the  commonwealth 
any  man  or  any  class  of  men  with  great  possibilities  and 
responsibilities  it  is  the  physician.  It  is  not  enough,  how- 
ever, to  work  at  the  individual  bedside  and  in  a  hospital. 
In  the  near  or  dim   future,  the   pediatrist,  the  physician, 

92 


HISTORY   OF   PEDIATRICS 

is  to  set  in  and  control  school  boards^  health  departments, 
and  legislatures.  He  is  the  legitimate  adviser  to  the  judge 
and  the  jury,  and  a  seat  for  the  physician  in  the  councils 
of  the  republic  is  what  the  people  have  a  right  to  demand. 
Before  all  that  can  be  accomplished,  however,  let  the 
individual  physician  not  forget  what  he  owes  to  the  com- 
munity now.  Mainly  to  the  young  men  amongst  us  I 
should  say,  do  not  forget  your  obligations  as  citizens. 
When  we  are  told  by  Lombroso  that  there  is  no  room  in 
politics  for  an  honest  man,  I  tell  you  it  is  time  for  the 
physician  to  participate  in  politics,  never  to  miss  any  of 
his  public  duties,  and  thereby  make  it  what  sometimes  it 
is  reputed  not  to  be  in  modern  life — honorable.  A  life 
spent  in  the  service  of  mankind,  be  our  sphere  large  or 
narrow,  is  well  spent.  And  never  stop  working.  Great 
results  demand  great  exertions,  possibly  sacrifices.  After 
all,  whether  everything  in  science  and  politics  that  now  is 
our  ideal  will  be  accomplished  while  we  live  or  after  we 
shall  be  gone,  we  shall  still  leave  to  our  progeny  new 
problems. 

I 


93 


THE  HISTORY  OF  CEREBROSPINAL  MENIN- 
GITIS IN  AMERICA 

Nothing  is  more  difficult  to  ascertain  than  the  age  of 
certain  diseases,  which  by  reason  of  their  distribution 
and  mortality  have  attained  historical  significance.  The 
most  notable  in  the  category  is  syphilis.  The  number  of 
people  who  believe  it  to  have  sprung  from  nihility  at  the 
close  of  the  fifteenth  century,  or  who  consider  it  an  article 
of  importation  by  the  immoral  Indians  from  Indianola 
into  blissful,  innocent  Spain,  has  not  diminished.  Most 
likely   cerebro-spinal   meningitis   will   fare  the   same   fate. 

What  we  call  cerebro-spinal  meningitis  to-day  was  first 
described,  with  certainty,  in  1805.  Lersch  cites,  in  a 
short  note,  also  the  year  1803  {Volksseuchen,  1896),  but 
gives  no  data  of  the  literature.  In  all  probability  this 
disease  existed,  either  sporadically  or  endemically,  at  an 
earlier  period.  Meredith  Clymer  (Epidemic  Cerebro- 
spinal Disease,  Phil.  1872)  gave  expression  to  his  pre- 
sumption that  occasional  cases  with  a  similar  symptom- 
complex  had  been  observed  in  the  United  States  toward 
the  end  of  the  eighteenth  century. 

The  malignant  fever  which  Daniel  Sennert  describes  in 
l6ll  is  most  likely  one  and  the  same  disease,  and  later 
was  characterized  as  spotted  fever,  cerebro-spinal  typhus, 
cerebro-spinal  fever  and  cerebro-spinal  meningitis.  Ac- 
cording to  Webber  (Boylston  Prize  Essay  in  Boston  Med. 
and  Surg.  Jour.  1866),  from  the  thirteenth  century  on- 
ward, symptoms  descriptive  of  cerebro-spinal  meningitis 
have  been  enumerated.  The  accounts  have  not  always  been 
accurate,  "  the  principal  symptoms  have  been  variously 
depicted;  it  is  quite  likely  that  our  disease  and  exanthe- 
matous  typhus  were  often  mistaken  for  one  another,  like 
syphilis,  which  before  the  end  of  the  fifteenth  century  was 
often,  if  not  always,  confounded  with  measles  and  variola 

95 


DR.    JACOBI'S    WORKS 

(J.  K.  Proksch,  Beitrdge  zur  Geschichte  der  Syphilis, 
1904).  Sir  John  Pringle,  in  1752,  wrote,  in  his  observa- 
tions on  diseases  of  the  army,  about  a  prison  and  hospital 
fever  in  which  pus  was  found  on  the  brain,  and  Bascome 
in  his  history  of  epidemic  pestilences,  London,  1851,  re- 
fers to  a  local  epidemic,  in  Roettingen,  Bavaria,  in  1802, 
in  which  young,  strong  males,  with  painful  stiffness  of 
the  muscles  of  the  neck,  died  within  twenty-four  hours. 

The  best  history  of  cerebro-spinal  meningitis  of  all 
countries  is  to  be  found  in  the  third  volume  of  Historisch- 
Geographische  Pathologic  by  August  Hirsch,  1886.  The 
"  Epidemic  Cerebro-Spinal  Meningitis  and  its  relation  to 
other  forms  of  meningitis — a  report  of  the  State  Board 
of  Health  of  Massachusetts,  Boston,  1898,"  by  W.  T. 
Councilman,  F.  B.  Mallory  and  J.  H.  Wright,  offers 
valuable  contributions.  That  part  of  the  second  volume 
of  Puschmann's  Geschichte  der  Medicin,  edited  by  Victor 
Fossel,  is  quite  superficial.  The  Subject  Catalogue  and 
Index  Medicus  contain  naturally  everything  desirable,  and 
much  that  is  not  so. 

The  great  krrowledge  revealed  in  our  periodical  litera- 
ture is  collected  with  the  aid  of  a  secretary  from  the  above 
named  sources,  from  Virchow-Gurlt's  Jahresbericht  and 
other  encyclopaediae.  Without  quoting  these  works  too 
much  I  will  give  you  a  short  survey  of  the  occurrence  of 
cerebro-spinal  meningitis  in  the  United  States,  which  more 
often  than  any  other  country  has  been  irrv^aded  by  this 
plague.  Hirsch  divides  its  history  into  four  periods  1805- 
1837;  1837-1850;  1854-1875;  1876  up  to  the  time  that  his 
book  was  published — we  may  say,  with  interruptions,  until 
to-day.  In  the  first,  third  and  fourth  periods  the  United 
States  was  severely  affected,  whereas  during  the  second 
period  France  bore  the  brunt  of  the  disease.  It  is  to  be 
hoped  that  the  period  we  have  been  going  through  since 
last  year  is  not  the  precursor  of  a  fifth  period.  In  I8O6 
the  disease  was  epidemic  in  New  Hampshire,  Massachu- 
setts, Connecticut,  New  Jersey  and  Vermont ;  in  1 807  in 
Canada;  in  1808  in  Virginia,  Kentucky  and  Ohio;  1809  in 
New  York  and  Pennsylvania;  1814  in  Maine;  1814-1816 
in   New   England  in   general.      The  epidemic  then   gradu- 

96 


HISTORY     OF     CEREBRO-SPINAL     MENINGITIS 

ally  died  out.  However,  in  1823  we  hear  again  of  an 
epidemic  in  Middletown,  Conn.,  and  in  1828  in  Trum- 
bull, Ohio.      From  then  until   1842  we  have  no  data. 

The  most  important  contributions  to  the  literature  are 
by  L.  Danielson"  and  E.  Mann  (1806),  "A  singular  and 
very  fatal  disease  which  lately  made  its  appearance  in 
Medford,  Mass.,"  which  appeared  in  the  Medical  and 
Agricultural  Register,  Boston ;  further,  a  contribution  by 
a  committee  of  the  Massachusetts  Medical  Society  (James 
Jackson,  Thomas  Welch  and  J.  C.  Warren)  of  the  year 
1809,  printed  in  1813  in  the  second  volume  of  the  Trans- 
actions; and  above  all,  the  book  of  Elisha  North  of  1811, 
which  is  worthy  of  the  name  of  a  classic.  The  title  of  this 
book  which  contains  249  pages  is:  "A  Treatise  on  a 
Malignant  Epidemic  Commonly  Called  Spotted  Fever, 
etc." 

Dr.  North's  book  contains  among  other  things  the 
history  of  the  epidemic  of  Litchfield  county,  Connecticut, 
by  Dr.  Samuel  Woodward  of  Hartford,  besides  a  good 
description  of  the  clinical  picture  of  the  disease  by  Dr. 
Bertorf.  Under  the  influence  of  Brownianism,  which  did 
not  prevail  in  England,  although  it  was  prevalent  in  Ger- 
many and  America,  he  sought  the  immediate  cause  of  the 
disease  "  in  the  increase  in  the  sensorial  power  of  sensa- 
tion with  the  decrease  of  the  sensorial  power  of  irrita- 
tion." Whoever  cannot  understand  this,  must  console  him- 
self with  the  fact  that  during  the  following  30  or  40 
years,  medicine  in  Germany,  for  instance,  was  an  absolute 
blank,  with  indescribable  buncombe,  and  we  may  indeed 
congratulate  ourselves  that  we  have  outlived  the  era  of 
the  Svstems.  During  the  second  period  (according  to 
Hirsch)  the  disease  was  very  widespread  with  us,  from 
1842-1850;  in  1842  in  Rutherford  county.  Tennessee,  and 
in  Montgomery,  Alabama;  in  1845  in  Mt.  Vernon,  Illinois; 
in  1846  and  1847  in  Arkansas;  in  1847  in  Vicksburg,  Mis- 
sissippi, in  Tennessee  and  in  Missouri.  The  disease  was 
especially  virulent  amona:  the  recruits  of  a  regiment  that 
had  teen  sent  from  Mississippi  into  swampy  quarters  near 
New  Orleans.  In  1848  Montgomery,  Alabama,  was  af- 
fected   for  the   second   time ;    also    Pennsylvania   along  the 

97 


DR.    JACOBI'S    WORKS  V 

Ohio  river  and  Worcester^  Massachusetts.  In  1850  there 
was  a  severe  epidemic  in'  the  negro  quarters  of  New  Or- 
leans, as  we  find  it  among  populations  wlio  live  in  wretched 
hovels   with   insufficient   nourishment. 

From  1850-1856  the  United  States  were  free  from  the 
disease.  In  1856  and  1857  we  find  it  in  Salisbury,  North 
Carolina  (Dickson  in  Trans.  A.  M.  A.);  in  the  same  year 
it  prevailed  in  the  western  part  of  New  York,  especially 
in  Onondaga,  Chemung  and  Madison  (Thomas  in  Trans. 
Med.  So.  St.  of  N.  Y.).  During  the  war,  1861-1864,  the 
disease  was  far  reaching.  In  the  winter  of  1861-1862  it 
existed  in  the  Army  of  the  Potomac  near  Washington; 
likewise  in  a  negro  colony  quartered  by  the  Confederates 
in  Memphis.  In  1862  and  1863  it  appeared  in  the  camp 
around  New  Bern,  N.  C,  with  the  same  clinical  and  ana- 
tomical manifestations  which  had  been  observed  in  1810; 
and  also  in  Massachusetts  in  1861  and  1865.  Massa- 
chusetts then  remained  free  from  the  disease  until  it  ap- 
peared in  Boston  in  1872  and  1873  (J.  B.  Upham  in  Re- 
port of  the  State  Board  of  Massachusetts,  187'i).  It  had 
appeared  in  Philadelphia  in  1863.  This  epidemic  was  de- 
scribed in  1867  by  Alfred  Stille  in  a  monograph  which  has 
retained  its  value,  entitled  "  Epidemic  Meningitis."  The 
same  author  published  an  article  in  1885  in  Pepper's  Sys- 
tem of  Medicine,  which  is  still  very  instructive. 

During  the  epidemic  which  prevailed  at  Philadelphia 
in  1863-1866,  the  whole  city  was  severely  affected;  also 
Indiana  and  Iowa;  and  likewise  the  Confederate  troops 
in  Norfolk,  Va.,  whose  camps  were  pitched  in  swampy 
regions,  and  those  who  were  in  hospitals.  At  this  time  the 
disease  appeared  for  the  first  time  at  the  military  school 
in  Newport,  R.  I.  Mobile,  Ala.,  Illinois,  New  Jersey, 
Vermont  along  the  Connecticut  river,  Connecticut  and 
Ohio  were  severely  affected.  There  were  bad  epidemics 
in  two  hospitals  and  in  the  orphan  asylum  at  Washington. 

From  1860-1874  we  find  epidemics  over  the  entire  length 
of  the  land,  especially  during  the  winter  and  spring. 
After  1876  the  disease  showed  itself  sporadically  at  far 
separated  points.  In  1893  the  disease  once  more  became 
epidemic  in  New  York    (H.   Berg  in  Archiv.  Ped.  May, 

98 


HISTORY     OF     CEREBRO-SPINAL    MENINGITIS 

1894).  This  author  emphasizes  the  non-contagious  nature 
of  the  disease.  It  also  appeared  in  the  Layaconing  Val- 
ley in  Maryland  in  1893.  Simon  Flexner  and  Lewellys 
J.  Barker  in  the  Amer.  Jour,  of  the  Med.  Sc.  (February 
and  March,  1894)  describe  this  epidemic  from  a  prac- 
tical and  strictly  scientific  standpoint.  Appended  to  this 
article  there  is  a  two-page  bibliography  of  the  most  valu- 
able essays  on  this  subject.  In  some  of  their  cases  the 
pneumococcus   was    found. 

During  these  decades  the  disease  did  not  die  out.  Occa- 
sionally for  long  periods  the  mortality  was  low;  then 
suddenly  it  would  rise.  For  instance,  during  many  years 
only  isolated  cases  developed  in  Montreal;  so  also  in  the 
Boston  City  Hospital,  from  1880  to  1896,  only  39  cases 
died.  But  during  the  first  month  of  the  epidemic  of  1897 
there  were  42  fatal  cases.  Stille  reports  but  few  cases 
in  Philadelphia  from  1864-1865,  and  from  1872-1873. 
Pepper  carries  the  report  along  until  1892  and  Abbott 
brings  it  up  to  date.  How  rapidly  the  mortality  changes 
will  be  seen  from  the  following  figures:  Philadelphia  had 
in  1884,  124  deaths;  in  1893,  23  deaths;  in  the  succeeding 
years  seriatim,  22,  35,  18,  17,  7,  10;  24  in  1898,  and  in 
the  first  4  months  of  1899,  89  deaths. 

In  New  York  the  disease  was  endemic  in  1867-1868 
(Brown,  Med  Record,  April,  1868).  Somewhat  later, 
Ohio  and  Indiana  were  aiFected;  between  1869  and  1870 
we  find  the  disease  reappearing  in  Alabama,  Pennsylvania, 
and  Virginia,  in  1871  in  Minnesota  and  Pennsylvania,  in 
1872  in  New  Jersey,  the  cities  of  New  York  and  Brooklyn, 
Onondaga  county,  also  Illinois,  South  Carolina  and  part 
of  Georgia.  Concerning  Augusta,  Ga.,  I  was  kept  in- 
formed at  that  time  by  Dr.  Ford.  The  cases  were  not 
numerous  but  fulminating,  and  occurred  almost  exclusively 
among  the  most  miserable  class  of  negroes.  In  1873 
Massachusetts  suffered  severely,  Indiana  and  Michigan  to 
a  less  extent. 

Children  were  chiefly  affected  during  1806  in  Massa- 
chusetts, 1847  in  Tennessee,  1857  in  Elmira,  1863  in 
Philadelphia,  1864  in  Illinois,  1870  in  Virginia.  Adults 
between  20  and  30  years  were  chiefly  affected  in   1811   in 

99 


DR.    JACOBI'S    WORKS 

Milford,  Conrr.,  in  1848  in  Montgomery,  Ala.,  and  in 
1857  in  Brookfield,  N.  Y.  Out  of  2909  cases  reported 
from  Massachusetts  405  occurred  in  the  first  nine  months 
of  1897.  Of  these  there  were  316  under  one  year,  14-6 
between  one  and  two  years,  26  per  cent. 

I  herewith  present  a  list  compiled  by  the  New  York 
Board  of  Health.  In  considering  it,  the  increase  of  popu- 
lation from   1866  to  1904  must  be  taken  into  account. 


Cmxn  to  Gvim  m 

f^  ^^  "S  I  =?■&  iS^  ^ 

^'■2  "*::  i»-2  d  t^"Z  9"S  ^"Ti 

S;6  •§£  SS  §  is  ^S  SS 

O  H  m  0-i  u  H  in 

1866 18  588  486  767,979       .23  7.66  6.33 

1867 33  654  674  808,489       .40  8.09  8.34 

1868 34  627  820  851,137       .39  7.39  9.63 

1869 42  688  725  896,034       .47  7.68  8.09 

1870 32  812  750  943,300       .34  8.61  7.95 

1871 48  755  623  955,931       .50  7.90  6.52 

1872 782  770  848  968,710  8.07  7.95  8.75 

1873 290  682  666  981,671  2.95  6.95  6.78 

1874 158  627  563  1,031,607  1.53  6.08  5.46 

1875 146  599  643  1,044,396  1.40  5.74  6.16 

1876 127  613  697  1,075,532  1.18  5.70  6.48 

1877 116  514  556  1,107,597  1.05  4.64  5.02 

1878 97  604  569  1,140,617       .85  5.29  4.99 

1879 108  609  536  1,174,621   .92  5.18  4.57 

1880 170  617  582  1,209,196  1.41  5.10  4.82 

1881 461  675  764  1,244,511  3.70  5.42  6.14 

1882 238  659  714  1,280,857  1.86  5.15  5.57 

1883 223  541  719  1,318,264  1.69  4.10  5.45 

1884 210  683  797  1,356,764  1.55  5.03  5.87 

1885 202  639  844  1,396,388  1.45  4.58  6.04 

1886 223  721  872  1,437,170  1.55  5.02  6.07 

1887 203  621  952  1,479,143  1.37  4.20  6.44 

1888 173  493  914  1,522,341  1.14  3.24  6.00 

1889 145  543  839  1,566,801   .93  3.47  5.36 

1890 136  556  856  1,612,559   .84  3.45  5.31 

1891 189  583  932  1,659,654  1.14  3.51  5.69 

1892 230  605  1,020  1,708,124  1.35  3.54  5.97 

1893 469  607  1,160  1,758,010  2.67  3.45  6.60 


100 


HISTORY     OF     CEREBRO-SPINAL    MENINGITIS 


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1894 213  598  926  1,809,358  1.18 

1895 204  585  871  1,873,201  1.09 

1896 178  511  784  1,906,139  .93 

1897 232  517  755  1.940,553  1.20 

1898 258  593  782  1,976,572  1.31 

1899 287  609  742  2,014,330  1.42 

1900 201  585  544  2,053,979  .98 

1901 201  501  596  2,095,686  .96 

1902 190  571  633  2,139,632  .88 

1903 195  566  448  2,186,017  .89 

1904 1,083  470  588  2,235,060  4.85 

Absolute  figures,  however,  prove  nothing,  relative  ones 
much  more;  e.  g.  in  1866  the  population  of  New  York  was 
767,979;  in  1904  it  was  2,235,060.  You  will  notice  that, 
besides,  the  errors  of  another  kind  are  not  excluded.  The 
cerebral  diagnosis  of  many  doctors  who  fill  out  death  cer- 
tificates are  often  inaccurate.  This  list  contains  as  causes 
of  death,  cerebro-spinal,  tuberculous  and  "  simple  "  menin- 
gitis. In  the  first  six  years  1866-1871  the  percentage  of 
deaths  from  cerebro-spinal  meningitis  was  very  low,  in 
the  first  year  23-100  of  the  total  number  of  deaths.  Then 
we  find  a  sudden  increase  in  1872  to  8.07  per  cent.;  1873, 
2.95  per  cent.;  1874,  1.53  per  cent.;  1875,  1.40  per  cent. 
Then  there  followed  a  gradual  decrease.  In  1880  we  find 
it  rising  again  to  1.41;  1881,  3.70;  from  1882  to  1888 
the  mortality  varied  from  1.86  to  1.14.  In  1891  it  rose 
again  to  1.14;  1892,  1.35;  1893,  2.67;  1894,  1.18;  1895, 
1.09;  1896,  0.93;  1897,  1.20;  1898,  1.31;  1899,  1.42;  1900 
and  1901,  under  one  per  cent.;  1902  and  1903  under  O.9O; 
1904  it  again  rose  to  4.85.  Please  notice  that  the  mortal- 
ity percentage  during  1904  did  not  reach  double  that  of 
1893,  and  that  it  is  only  a  little  more  than  half  as  large 
as  during  the  epidemic  of  1871.  However,  the  782  deaths 
of  the  year  1872  are  much  more  terrible  (in  a  population 

101 


DR.    JACOBI'S    WORKS 

of  less  than  one  million)  than  the  1083  deaths  of  the  yeai" 
1904  with  a  population  of  2^  million. 

For  comparison  I  present  to  you  the  list  of  deaths  of 
the  past  three  months  of  1905,  again  from  the  official 
figures.  In  1905  there  died  in  Manhattan,  not  in  Greater 
New  York: 

Cer.  Sp.  Men.     Mening.     Tub.  Men. 

In  January 94        144         40 

In  February 139        179         36 

In  March 295        259         37 


528 


582 


113 


You  will  notice  that  the  alleged  increase  of  deaths  due 
to  simple  meningitis  has  been  doubled  in  two  months.  One 
cannot  but  surmise  that  many  of  these  cases  may  have 
been  those  of  cerebro-spinal  meningitis.  On  the  other 
hand  we  must  not  forget  that  during  an  epidemic  many 
deaths  are  wrongly  attributed  to  the  disease  then  prevalent. 
The  above  figures  are  increased  from  10  to  12  per  cent, 
by  including  all  the  cases  occurring  in  Greater  New  York. 

The  following  list  proves  this  clearly: 


Greater  New  York. 


Manhattan. 


Bronx. 


M. 


F.    Total.     M.        F.    Total.     M.     F.     To. 

I        4       13 


26 
23 

28 
16 
22 
29       80 


13 
8 

10 
9 

13 


1898 201  156       357  131  114      245  9 

1899 223  171       394  150  111       261  13 

1900 174  132       306  103         75       178  15 

1901 152  115       267         92        81       173  18 

1902 145  120       265         96         78       174  7 

1903 151  120      271  100         73       173  9 

1904 759  642  1,401  532  471  1,003  51 

Brooklyn.                  Queens.  Richmond. 

M.  F.  Total.  M.  F.     Total.  M.     F.  Total. 

1898 52  30        82  9  5  14  . .         3  3 

1899 52  30         94  5  4          9  3         1  4 

1900 50  43        93  4  4          8  2        2  4 

1901 37  20         57  5  3          8  ..         1  1 

1902 33  24        57  4  7  11  5         2  7 

1903 31  26         57  8  10  16  3         1  4 

1904 147  128  275  20  9  29  9         5         14 

102 


HISTORY    OF     CEREBRO-SPINAL    MENINGITIS 

We  find  the  largest  mortality  from  cerebro-spinal  menin- 
gitis in  Manhattan  in  the  4th,  5th,  6th,  7th,  8th  and  14th 
wards.  These  are  the  wards  in  which  we  meet,  besides 
other  social  atrocities,  the  largest  number  of  dark  rooms, 
of  which  there  were  two  years  ago  in  Manhattan  212,615, 
in  Brooklyn  139,928,  in  Queens  8,666  and  in  Richmond 
452. 

Of  the  cases  under  15  years  of  age  there  died  of  cerebro- 
spinal meningitis  in  New  York: 

1895 167 

1896 15T 

1897 201     In  Greater  New  York.  All  ages. 

1898 210  301  357 

1899 232  326  394 

1900 153  251  306 

1901 165  221  267 

1902 156  221  265 

1903 158  225  271 

1904 805  1056  1401 

The  proportion  of  children  that  died  compared  with  the 
number  of  deaths  in  Manhattan  is  accordingly  as  805:- 
1003;  and  for  Greater  New  York  as  1056:1401.  That  is 
to  say  that  in  the  boroughs  outside  of  Manhattan  the  mor- 
tality among  adults  was  higher  than  among  children. 
Everywhere,  however,  the  large  majority  of  cases  are 
children. 

Distribution.  The  disease  occurs  in  the  temperate 
and  sub-tropical  zones  and  is  therefore  adapted  to  the 
United  States.  It  is  found  most  frequently  in  the  winter 
and  spring.  .Of  85  epidemics  occurring  in  North  America, 
there  were  37  in  the  winter,  18  in  the  winter  and  spring, 
and  23  in  the  spring.  Low  temperatures  and  the  presence 
of  catarrhal  disease  are  mentioned.  However,  we  find  the 
disease  even  in  mild  winters,  e.  g.,  1862  in  Connecticut  and 
1866  in  Kentucky.  Many  similar  ones  are  referred  to  by 
Hirsch  (pages  398  and  399).  On  the  other  hand,  dur- 
ing some  very  cold  winters  we  find  only  one  city  or  region, 
one  class  of  people,  or  one  regiment  of  soldiers,  affected, 
According  to  Frothingham  in  1861-1862  one  regiment  that 

108 


DR.    JACOBI'S    WORKS 

was   particularly  well   quartered  was   afflicted  with  menin- 
gitis, while  other  regiments  suffered  from  malaria. 

The  epidemic  character  of  the  disease  has  been  too  fre- 
quently observed  to  be  questioned.  Occasionally  it  ap- 
pears sporadically.  About  30  years  ago  there  were  two 
parts  of  New  York  where  the  disease  was  very  prevalent, 
the  neighborhood  of  Chatham  Square,  James  and  Oliver 
streets,  and  the  neighborhood  south  of  West  Houston 
street  and  west  of  McDougall  street.  At  that  time  I  saw 
two  fatal  cases  within  one  week  in  a  room  in  Charlton 
street.  The  one  case  was  a  baby  of  6  months  that  died  in  8 
hours,  the  other  a  child  of  2  years  that  died  in  20  hours. 
The  autopsy  in  one  case  showed  the  usually  prevalent  fibri- 
nous exudate.  Different  authors  have  diff"erent  views  con- 
cerning the  spread  of  the  disease,  especially  direct  conta- 
gion. Vieusseux,  who  described  the  Geneva  epidemic  of 
1805,  dclared  the  disease  to  be  non-contagious.  He  gave  as 
his  reason  for  this  belief  the  fact  that  when  two  cases 
occurred  in  one  family,  they  developed  at  the  same  time. 
North  states  in  his  book  of  1811  that  travelers  who  came 
from  an  immune  place  to  an  infected  one  contracted  the 
disease.  He  attributed  it  either  to  contagion  or  to  local 
influences.  According  to  Hirsch,  in  the  first  large  epidemic 
in  Franken  the  disease  spread  in  a  regular  course  from 
northeast  to  southwest.  Love  reports  that  in  1847  only 
one  regiment  in  New  Orleans  was  aff"ected.  One  French 
regiment,  in  which  meningitis  was  prevalent  in  1840,  was 
transferred  to  Algiers.  After  a  short  time  natives  also 
were  afflicted,  the  only  time  that  the  disease  was  ever  ob- 
served in  North  Africa.  During  our  war  meningitis  de- 
veloped in  public  institutions  after  an  infected  regiment 
hfd  been  qnnrtered  in  the  city.  Nowlin  in  the  Jour,  of 
the  Am.  Med.  Assoc,  1891,  reports  five  cases  in  Shelby - 
ville,  Tenn.,  of  which  two  developed  in  one  house.  Such 
occurrences  are  not  isolated.  Hence  it  is  not  of  much  mo- 
ment when  occasionally  an  observer,  as  for  instance  H. 
Berg.  {Arch.  Pediatrics,  1894),  reports  that  he  never  ob- 
served two  cases  in  one  house.  I  have  had  no  personal 
experience  of  contagion  in  any  of  my  hospital  services. 
However,  last  week  a  nurse  at  the  Harlem  Hospital,  who 

104 


HISTORY     OF     CEREBRO-SPINAL    MENINGITIS 

had  taken  care  of  meningitis  cases,  died  of  the  disease. 
In  like  manner,  Dr.  Craig  of  Philadelphia  died  a  martyr 
to  his  duty.  In  1904  most  of  my  hospital  cases  suffered 
from  nasal  catarrh;  in  many  cases  the  coccus  was  found 
in  the  secretion,  in  one  case  also  in  the  conjunctival  secre- 
tion. No  infection  of  other  patients  in  the  ward  was  ob- 
served. Whether,  as  in  malaria  and  yellow  fever,  an  in- 
termediary agent  of  infection  such  as  the  mosquito  is  re- 
quired, or  as  in  recurrent  fever  the  bedbug,  remains  to 
be  proven. 

Dr.  E.  G.  Janeway  had  the  following  experience:  The 
coffin  containing  the  body  of  a  woman  who  had  died  of 
cerebro-spinal  meningitis  was  opened,  and  a  strand  of 
her  hair  cut  off.  This  strand  was  taken  home  by  a  wo- 
man, and  frequently  handled  by  her  as  well  as  by  a  child 
living  in  the  same  house.  Both  this  woman  and  the  child 
developed  meningitis,  and  nobody  else  in  the  house  was 
affected. 

In  the  United  States  a  disproportionately  large  number 
of  negroes  was  afflicted.  In  New  Orleans  in  1850  only 
negroes  contracted  the  disease;  likewise  in  Memphis,  1862- 
1863,  those  that  were  huddled  together  there  by  the  Con- 
federates were  the  only  ones  affected.  In  like  manner 
only  negroes  were  stricken  in  Mississippi  in  1862,  in  Mary- 
land and  in  Mobile,  Ala.,  in  1864,  and  in  Philadelphia  in 
1867.  However,  A.  Hirsch,  who  did  not  know  of  the  con- 
ditions from  personal  observation,  correctly  surmises  that 
not  the  race  but  the  lodging,  food,  and  general  social 
conditions  are  responsible  for  the  development  of  the  dis- 
ease. Whoever  has  observed  the  conditions  in  the  south 
can  verify  this  statement.  I  have  recently  visited  one  of 
the  most  civilized  southern  communities,  Augusta,  Ga. 
There  are  two  negro  quarters.  In  one  of  them  an  intelli- 
gent negress  has  for  a  dozen  or  more  years  been  conduct- 
ing a  school  for  children  of  from  6  to  16  years.  I  saw 
hundreds  of  cleanly  washed  children  both  at  work  and  at 
play,  in  clean,  almost  holiday  attire.  I  was  so  struck 
that  I  inquired  if  it  was  a  holiday.  These  four  or  five 
hundred  children  were  all  from  the  neighborhood.  The 
houses,  as  well  as  the  inhabitants,  were  clean,  and  there 

105 


DR.    JACOBI'S    WOllKg 

was  a  little  garden  in  front  of  each  house.  Evidently  the 
teacher  and  the  children  infected  the  entire  suburb  with 
their  culture.  There,  in  all  likelihood,  meningitis,  if  at 
all,  will  develop  equally  among  the  white  and  colored  peo- 
ple. In  another  suburb  I  saw  no  gardens,  no  paint  on  the 
miserable  reeking  dwellings,  and  no  clean  linen  on  the 
line.     Here  we  shall  find  meningitis  in  the  future. 


106 


CEREBROSPINAL  MENINGITIS— SYMPTOMA- 
TOLOGY   AND    TREATMENT 

SYMPTOMATOLOGY 

It  is  not  worth  the  while  this  evening  to  go  deeply  into 
the  symptomatology  of  the  disease  in  general.  I  am  not 
diligent  enough  to  go  through  all  the  modern  journal 
literature  and  from  six  books  compile  a  new  one  nor  to 
compile  a  new  paper  from  manuals.  You  know  from  ex- 
perience how  one  learns  to  disdain  this  kind  of  fame.  But 
I  will,  in  a  few  remarks,  relate  what  during  the  last  year 
and  a  half  appeared  surprising  to  me  and  was  at  variance 
with  earlier  observations. 

The  usual  symptoms  were  headache,  torticollis,  vomiting 
in  most  cases  one  or  more  times,  occasionally  convulsions 
and  coma,  sometimes  early  but  most  often  towards  the  end. 
Kernig's  sign  was  present  in  all  but  two  cases — in  a  pa- 
tient of  25  years  and  one  of  4  years. 

Spots  were  not  always  present  early,  but  at  some  time 
or  another  during  the  course  of  the  disease;  in  a  small 
number  of  cases  strictly  ischemic  but  becoming  hyperemic 
after  many  minutes  and  remaining  for  several  minutes 
longer. 

In  some  cases  the  phenomena  were  unilateral  at  first 
and  only  gradually  showed  themselves  on  both  sides  of 
the  body.  A  child  of  3  years  had  a  right  total  hemiplegia 
that  was  distinct  for  weeks,  besides  general  symptoms. 

The  pupils  were  almost  always  alike:  in  the  beginning 
of  the  diseases  they  were  contracted  as  a  rule,  and  later 
on,  as  coma  increased,  dilated;  in  every  case  they  re- 
sponded but  slowly  to  light  and  in  rare  instances  not  at  all. 

What  I  have  just  said  is  in  direct  contradiction  to 
my  observations  during  the  epidemic  thirty  years  ago. 
There  I  almost  without  exception  found  the  pupils  strongly 

107 


DR.    JACOBI'S    WORKS 

dilated  from  the  very  beginning  of  the  disease,  with  no 
response  or  very  little  to  the  influence  of  light;  and  this 
symptom  was  considered  as  pathognonomic  for  the  disease, 
and  was  ascribed  by  me  to  irritation  of  the  cervical  gan- 
glion controlling  the  dilator  pupillae.  It  is  worth  the 
while  to  experience  several  epidemics  of  the  same  infectious 
disease. 

I  had  a  similar  experience  with  the  spots.  In  every 
earlier  epidemic  they  appeared  on  the  first  day  with  such 
regularity  that  I  believed  also  this  symptom  could  be  used 
for  differentiation  from  other  forms  of  meningitis.  And 
this  I  taught  up  to  a  few  years  ago,  but  have  since 
learned  better.  There  are  very  many  ways  in  which  to 
err. 

Among  58  cases  there  were  petechise  in  8,  erythema 
with  petechiae  in  1,  papulous  eruption  in  1,  general  hy- 
peremia with  pustules  in  1,  uniform  hyperemia  in  1,  and 
mottled  hyperemia  in  1  case,  herpes  in  a  small  proportion 
of  the  cases,  and  not  at  a  definite  period  of  the  disease; 
if  it  indicates  an  attack,  it  must  be  inferred  that  its  ap- 
pearance was  belated  for  any  length  of  time  up  to  the  end 
of   the   third   week. 

Apparently  during  the  present  epidemic  the  skin  is  not 
implicated  as  it  was  in  former  epidemics.  Such  differ- 
ences are  noted  in  the  literature  of  various  years  and 
different  localities.  Vieusseux  in  his  report  on  the  Geneva 
epidemic  in  1805  does  not  mention  skin  lesions  at  all, 
while  North  refers  to  their  frequent  occurrence  in  the 
epidemic  of  1811.  The  name  "spotted  fever"  dates 
from  that  time,  and  Upham  speaks  of  the  possibility  of 
confounding  the  disease  with  typhus. 

General  hyperesthesia  was  very  rare,  which  is  decidedly 
at  variance  with  the  general  behavior  of  former  epidemics. 

Opisthotonos  in  a  high  degree  was  rarely  pronounced, 
torticollis  always;  moderate  rotation  of  the  head  was  pos- 
sible in  many  cases,  and  in  a  few  was  even  easy  and  pain- 
less. 

Nasal  catarrh  was  common  last  year  (1904)  but  rare 
this  year  (1905). 

108 


CEREBRO-SPINAL    MENINGITIS 

In  a  few  instances  taking  a  slow  and  fatal  course  ir- 
regular breathing  of  a  Cheyne-Stokes'  character  set  in 
early. 

The  deafness  remaining  after  epidemic  cerebro-spinal 
meningitis  is  probably  not  to  be  viewed  in  the  sense  in 
which  it  was  described^  by  Voltolini,  who  (Mon.  f.  Ohr., 
1867)  looked  upon  it  as  an  independent  inflammation 
of  the  labyrinth.  According  to  him  it  announced  itself 
by  intense  headache,  vomiting,  high  temperature  and  con- 
vulsions, which  continued  for  several  days  and  generally 
ended  in  recovery,  but  with  deafness  and  trembling  gait. 
It  is  probable  that  he  had  before  him  as  a  rule  cases  of 
cerebro-spinal  meningitis  of  short  duration.  I  observed 
deafness  as  an  incurable  sequel  of  the  disease  more  fre- 
quently  last   year   than  this. 

Blindness  I  have  never  seen  in  patients  recovering.  Os- 
ier {Johns  Hopkins  Hospital  Bull.,  1892)  reports  a  case 
of  chronic  cerebro-spinal  meningitis  the  secondary  blind- 
ness in  which  disappeared  after  a  long  period. 

Other  complications  I  have  seen  only  very  seldom  this 
year.  Among  the  many  cases  treated  at  the  Roosevelt 
Hospital  there  was  only  one  case  of  arthritis,  one  case  of 
purulent  pericarditis  found  at  the  autopsy.  Pneumonia 
seems  to  have  been  very  rare  this  year;  consecutive  neuritis 
I  have  not  seen,  most  patients  do  not  live  long  enough  to 
get  it.  Renal  irritation  in  the  beginning  does  not  seem 
to  lead  to  nephritis. 

The  spleen  is  not  so  swollen  as  it  is  in  the  majority  of 
other   infectious  diseases. 

Councilman,  as  well  as  Jaeger  {Zeit.  f.  Hyg.,  xix.,  1895), 
believed  that  animals  in  general  are  inaccessible  to  inocu- 
lation with  the  meningococcus ;  but  Heubner  produced  the 
disease  (Jahrb.  f.  Kinderk.,  1896;  Deut.  Med.  Woch., 
1897)  by  introducing  cultures  into  the  spinal  canal  of 
goats.  The  entrance  to  the  central  nervous  system  thus 
appears  to  be  easy  enough  anatomically.  The  extensive- 
ness  of  the  lymphatic  network  in  the  nose, -the  conjunctiva 
and  the  ear,  the  frequency  of  wounds  of  the  surface  in 
these  organs,  the  thinness   of  the   plate  of  the  ethmoidal 

109 


DR.    JACOBI'S    WORKS 

bone,  make  it  appear  really  wonderful  that  Weichselbaum's 
diplococcus,  which  was  found  also  in  the  conjunctiva  by 
Schwabach  in  1891,  and  in  otitis  by  Scherer  (the  same 
diplococcus  that  was  found  by  Heubner  in  1896  in  the 
subarachnoid  fluid),  does  not  more  often  reach  the  interior 
of  the  central  nervous  system. 

In  those  cases  where  the  disease  is  confined  to  the  nerve 
centres,  direct  infection  from  person  to  person  must  be 
very  difficult. 

From  an  anatomical  point  of  view  all  cases  of  menin- 
gitis are  cerebro-spinal,  that  is,  the  brain  and  spinal  cord 
are  affected  simultaneously.  The  arachnoid  and  pia 
should  not  be  considered  separately.  The  former  con- 
stitutes the  serous  surface  connected  with  the  dura  and 
one  side  of  the  subdural  space.  The  pia  represents  a 
loose  connective  tissue  containing  lymph  spaces  and  blood- 
vessels. As  the  choroid  plexus  this  total  membrane  ex- 
tends into  the  ventricles.  In  the  spinal  cord  the  serous 
arachnoid  and  the  pia  are  separated  somewhat  and  form  a 
real  subdural  space,  but  are  connected  by  numerous  fibrous 
trabeculae. 

If  in  meningitis  the  spinal  cord  is  affected  more  pro- 
foundly than  the  brain,  and  especially  if  the  presence  of 
the  meningococcus  intracellularis  is  considered  of  etiologi- 
cal importance,  we  are  in  the  habit  of  referring  to  it  as 
cerebro-spinal  inflammation.  In  its  epidemic  appearance 
the  membranes  of  the  spinal  cord  are  affected  more  de- 
cidedly than  at  other  times,  but  the  inflammation  progresses 
along  the  course  of  the  nerves  and  into  the  substance  of 
the  central  organs.  Changes  in  the  tunica  intima  do  not 
occur,  however,  in  cerebro-spinal  meningitis.  In  contra- 
distinction to  this,  in  tuberculous  meningitis  tuberculous 
deposits  occur  along  the  course  of  the  vessels  and  in  the 
fibrino-purulent  exudate.  True,  the  staphylococcus  aureus, 
the  streptococcus  and  the  diplococcus  lanceolatus  produce 
epidemic  cerebro-spinal  meningitis,  but  they  can  be  differ- 
entiated by  their  behavior  in  other  tissues.  Finally,  the 
greater  or  lesser  extent,  depth  and  copiousness  of  the  ex- 
udate, and  the  suddenness  or  slowness  of  the  intoxication, 

no 


CEREBRO-SPINAL    MENINGITIS 

afford  the  best  explanation  of  the  variability  of  the  symp- 
tomatology. 

TREATMENT 

Preventive  measures  cannot  positively  prove  to  be  ef- 
fective, with  the  exception  possibly  as  immunizing  doses 
of  an  antitoxin.  Inasmuch  as  in  cerebro-spinal  meningitis 
the  invasion  probably  occurs  only  through  the  mucous 
membranes,  the  old  rule  holds  which  I  have  recommended 
since  forty  years  in  connection  with  diphtheria,  namely: 
to  keep  the  nose  and  throat  healthy.  I  cannot  understand 
why  a  modern  author  recommends  the  particularly  mildly 
antiseptic  boric  acid  as  a  general  prophylactic. 

There  can  scarcely  be  anything  less  consoling  than  a 
resume  of  the  various  treatments  that  have  been  proposed. 
They  seem  to  have  had  no  influence,  positively  less  than 
the  character  of  the  epidemics,  the  mortality  having  ranged 
from  30  per  cent,  to  90  per  cent.  In  my  own  experience, 
which  extends  over  several  epidemics,  the  death-rate  has 
been  from  30  per  cent,  to  70  per  cent.  A  summary  of 
various  methods  of  treatment  is  given  in  a  paper  read 
by  Stockton  two  months  ago  before  the  State  Medical 
Society  and  since  published  in  the  March  number  of  the 
Albany  Medical  Annals.  What  I  have  advised  during 
four  dozen  years  can  be  found  in  ray  "  Therapeutics." 
Let  me  briefly  relate  what  I  did  myself  and  what  I  ob- 
served. The  main  thing  in  every  case,  whether  severe  or 
mild,  is  isolation,  rest  and  moderate  darkness.  I  deem  it 
well  to  keep  the  head  raised,  rather  by  raising  the  head  end 
of  the  bed  than  by  the  use  of  pillows  only.  It  is  essen- 
tial to  give  sufficient  food,  as  the  disease  may  last  for 
weeks  and  months  and  death  not  seldom  sets  in  from  in- 
anition or  imder  symptoms  of  starvation.  Therefore  every 
remission  of  temperature  should  be  utilized  for  feeding. 
If  vomiting  be  frequent,  small,  oft-repeated  meals  must  be 
given.  Such  a  meal  is  occasionally  retained  if  1  or  2 
drops  of  Magendie's  solution  or  a  2-mg.  (^o  grain)  tablet 
of  morphine  have  been  put  into  the  mouth  a  few  minutes 
before,  as  far  backward  as  possible.  Once  in  a  while 
feeding  through  the  stomach  tube  becomes  necessary,  and 

111 


DR.    JACOBI'S    WORKS 

I  have  it  done  three  or  four  times  daily.     Rectal  alimen- 
tation is  seldom  successful. 

Rest  at  night,  and  even  also  by  day  as  far  as  prac- 
ticable, should  be  insisted  upon.  Bromides  have  proved 
of  little  avail,  hyoscine  useless ;  chloral  by  enema  one  or 
more  times  a  day  in  doses  of  0.03  to  0.05  gm.  (^  to  ^- 
grain)  has  sometimes  had  the  desired  effect;  the  best  re- 
sults were  obtained  with  the  opiates — morphine  and  most 
often  codeine — in  not  too  small  doses. 

A  very  up-to-date  city  colleague  claims  to  have  obtained 
marvelous  results  with  the  continued  administration  of  large 
doses  of  morphine.  We  will  probably  at  an  early  date 
read  an  "  interview  "  in  some  papers !  The  matter  is  of 
no  further  value. 

The  head  should  be  covered  with  an  ice-cap,  and  if 
possible  a  small  bag  should  also  be  put  at  the  back  of 
the  neck,  but  the  latter  application  is  difficult  and  at  times 
impossible. 

Occasionally  I  applied  leeches  to  the  nape  of  the  neck 
and  the  mastoid  processes.  Cupping  I  did  not  do,  nor 
have  I  resorted  to  bleeding  since  twenty  years.  A  purga- 
tive should  be  given  in  the  beginning  of  the  treatment, 
preferably  calomel.  What  is  ordinarily  a  large  dose  may 
prove  insufficient;  it  is  not  rare  to  meet  with  a  child  3  or 
4  years  old  who  has  taken  as  much  as  0.5  gm.  (7i  grains) 
of  calomel  in  half  a  day,  without  the  desired  purgative  ef- 
fect or  any  other  particular  result.  Vinegar  and  water 
enemas  may  assist  the  action.  Saline  purgatives  are  indi- 
cated, but  it  is  rarely  easy  to  give  them.  Baths  are  useful, 
but  difficult  to  employ,  because  the  patients  are  obdurate 
and  suffer  considerably  during  the  manipulation.  Hot 
baths  I  scarcely  ever  gave.  Sponging  with  alcohol  and 
water  should  be  practiced  for  well-known  reasons  and  has 
some  effect.  Should  it  not  have  sufficient  influence  upon 
high  temperature,  small  doses  of  phenacetine  may  be  ad- 
ministered, preferably  combined  with  a  small  quantity  of 
caffeine.  Antipyrine  I  have  used  in  this  disease  but  little ; 
during  the  many  years  that  I  have  known  this  remedy  it 
has  seemed  to  me  to  fail  to  exert  its  usual  action  in  brain 
trouble. 

112 


CEREBROSPINAL    MENINGITIS 

Symptoms  of  weakness  I  have  combated  with  camphor, 
musk  or  caffeine,  seldom  with  alcohol. 

I  have  been  partial  to  the  iodides,  particularly  sodium 
iodide,  and  in  larger  doses,  that  is,  the  smallest  receive 
as  much  as  5  to  8  gms.  (1^  to  2  drachms)  daily.  They 
arg  well  borne  as  in  all  forms  of  meningitis,  and  they  show 
themselves  promptly  in  the  urine.  For  about  ten  years  I 
was  as  obstinate  as  the  disease;  but  the  disease  I  regret 
to  say  has  exhausted  my  patience.  Since  four  or  five 
weeks  I  have  completely  abandoned  the  iodide  treatment, 
and  my  results  have  not  been  any  poorer  than  formerly. 
In  olden  times  I  employed  sublimate  hypodermically,  but 
without  visible  benefit.  Six  weeks  ago  a  5-months  old  child 
was  brought  to  me  at  the  hospital  with  cerebral  symptoms 
— striped  look,  slow  reaction  of  the  moderately  dilated 
pupils,  slight  Kernig,  sallow  skin  with  mild  yellow  dis- 
coloration around  the  eyebrows  and  very  slight  torticollis. 
To  me  the  diagnosis  of  syphilitic  hydrocephalus  appeared 
more  probable  than  any  other,  and  I  even  dispensed  with 
lumbar  puncture.  The  child  took  thrice  daily  0.003  gm. 
(%o  grain)  of  sublimate  and  0.05  gm.  (f  grain)  of  sodium 
iodide,  and  seemed  to  improve  a  little  after  a  week  or  two. 
But  after  three  weeks  the  torticollis  increased  and  the  men- 
ingococcus was  present  in  the  turbid  spinal  fluid.  The 
case  ended  fatally. 

During  the  period  in  which  I  employed  the  iodides  as 
the  routine  treatment  I  did  not  perform  lumbar  puncture 
in  every  case ;  since  that  it  has  been  the  rule  with  me,  partly 
as  a  diagnostic  measure  and  in  part  as  a  remedy.  A  single 
puncture  does  not  always  suffice  to  establish  the  diagnosis; 
sometimes,  when  made  early,  the  coccus  is  not  found,  but 
will  be  after  one  or  several  days.  More  frequently  it  hap- 
pens, however,  that  the  coccus  appears  two  or  three  times 
and  then,  after  a  few  days  more  disappears  again,  as  the 
cases  may  vary  also  in  other  waj's.  Occasionally,  but  rarely, 
only  a  small  quantity  of  a  thick  fluid  exudes ;  and  some- 
times there  is  no  flow  at  all.  Here  probably  the  foramen  of 
Magendie  is  occluded.  In  many  cases,  however,  the  fluid 
is  under  pressure  and  the  first  20  cc.  or  30  cc.  flow  out  in 
a  stream ;  gradually  the  pressure  diminishes.     I  have  rarely 

113 


DR.    JACOBI'S    WORKS 

drawn  off  or  been  able  to  get  more  than  30  cc.  In  these 
cases  I  have  occasionally  seen  a  lessening  of  the  coma, 
but  no  eft'ect  upon  the  moderate  dilation  of  the  pupils.  J 
am  of  the  opinion  that  lumbar  puncture  is  indicated  in 
many  cases,  while  I  have  never  seen  it  have  a  harmful 
effect  in  any.  I  performed  it  in  many  cases  three  or 
four  times  or  even  oftener,  for  our  cases  as  a  rule  gave  us 
only  too  much  time  for  its  performance.  A  child  of  4 
years,  in  whom  constant  drainage  was  kept  up,  died. 

Crede's  ointment  I  used  in  two  cases ;  collargol  I  em- 
ployed per  rectum  in  doses  of  0.1  to  0.2  gm.  (1^  to 
3  grains)  dissolved  in  1  to  2  tablespoonfuls  of  boiled  water, 
in  two  other  cases  for  weeks,  once  or  twice  daily,  but 
without  demonstrable  benefit. 

In  view  of  the  hopelessness  of  the  treatment,  I  made  a 
trial  during  the  last  five  or  six  weeks  also  of  diphtheria 
antitoxin.  Dr.  Weitzfelder  had  favored  me  with  informa- 
tion on  the  subject  before  he  published  his  experiences  or 
his  views.  I  take  it  for  granted  that  the  method  and  its 
theory  as  propounded  by  Dr.  Wolf  of  Hartford  are  known 
to  you.  Dr.  Wolf  discovered  in  his  laboratory  that  there 
was  an  antagonism  between  the  antitoxin  and  cultures  of 
the  meningococcus.  The  doses  I  employed  subcutaneously 
or  by  intramuscular  injection  were  those  recommended  to 
me  by  Dr.  Weitzfelder,  namely:  6000  units  for  children. 
I  gave  from  three  to  six  such  doses  in  the  course  of  as 
many  or  more  days.  My  results  were  negative,  as  were 
also  those  obtained  by  my  colleagues  in  other  divisions 
of  Roosevelt  Hospital.  Quite  a  number  of  cases  were 
treated,  without  appreciable  effect.  I  then  proceeded  in 
a  manner  outlined  by  Dr.  Francis  Huber,  a  colleague  of 
Dr.  Weitzfelder  at  the  Gouverneur  Hospital  and  Physi- 
cian to  the  Beth  Israel  Hospital,  who  had  an  abundance 
of  material  at  his  disposal.  I  injected  1500  units  of 
diphtheria  antitoxin  into  the  spinal  canal,  after  withdraw- 
ing the  usual  quantity  of  fluid. 

I  made  about  40  such  injections,  and  the  results  con- 
firmed the  old  story  that  not  all  laboratory  observations 
can  be  utilized  clinically.  My  best  case,  which  will  shortly 
be  discharged  as   cUred,  did  not   receive   any  injection  or 

114 


CEREBROSPINAL    MENINGITIS 

any  kind  of  treatment  whatever.  Several  of  the  injected 
cases  are  doing  very  badly,  some  are  in  a  fairly  good 
state — just  like  the  other  cases,  receiving  different  treat- 
ment or  going  without  treatment.  Unfortunately,  in  in- 
ternal medicine  many,  very  many,  cases  are  necessary  to 
try  out  any  particular  remedy  or  method  of  treatment 
and  arrive  at  a  positive  conclusion.  Nothing  is  more 
deceiving  than  premature  reports  in  our  journal  liter- 
ature, written  with  an  enthusiastic  desire  to  teach 
something  new  and  useful,  but  really  playing  into  the 
hands   of  whimsical   doubt   and   even   unjustified   nihilism. 

My  hospital  colleagues  did  just  as  I  did.  The  Depart- 
ment of  Health  placed  at  our  disposal  countless  thousands 
of  units. 

A  few  of  our  cases  are  briefly  described  in  the  follow- 
ing: 

Man  of  28,  sudden  attack,  petechiae,  coma,  high  tem- 
perature. 12,000  units  injected  subcutaneously  on  second 
day,  10,000  more  12  hours  later  and  8400  on  third  day, 
making  30,400  units  in  all.  Died  on  fourth  day.  Several 
lumbar  punctures  had  been  made. 

Man  of  18,  case  similar  to  preceding.  12,000  units  hy- 
podermically  on  second  and  third  days.  Died  on  third 
day. 

Child  of  8  years,  severe  case.  6000  units  subcutane- 
ously on  second,  sixth  and  seventh  days,  1500  intraspinally 
on  eleventh  and  eighteenth  days.     Not  quite  dead  as  yet. 

Child  3^  years  old,  mild  case.  Vomiting,  delirium,  tor- 
ticollis. 6000  units  on  third,  fifth,  seventh  and  tenth  days, 
subcutaneously,  1500  intraspinally  on  twelfth  day.  On 
twenty-eighth  day  temperature  still  intermittent  but  grad- 
ually falling,  spinal  fluid  clear. 

Man  of  41,  severe  attack,  only  occasionally  conscious. 
2000  units  intraspinally  on  fifth  and  seventh  days.  Died 
on  eighth  day. 

Child  of  6  years,  severe  attack,  unconsciousness,  convul- 
sions. 1500  units  intraspinally  on  third  day.  On  eighth 
day  still  high  temperature,  but  conscious. 

Child  of  8  years,  severe  case,  with  chills,  headache,  de- 
lirium, opisthotonos.      1500   units   intraspinally  on   fourth 

115 


DR.    JACOBI'S    WORKS 

day,  on  seventh  1500,  on  tenth  2000,  on  eighteenth  1500 
and  on  twenty-third  600  units  subcutaneously.  On  twenty- 
fourth  day  brain  and  spinal  fluid  clear.  Temperature 
intermittent.      Deaf. 

Child  of  7  years,  sudden  attack,  chills,  headache,  vom- 
iting, torticollis.  On  third  and  fifth  days  1500  units  intra- 
spinally.  On  fifteenth  day  temperature  between  98°  and 
101°  F.,  consciousness  returned,  neck  less  stiff,  some 
appetite. 

Child  of  6  years,  mild  attack,  convulsions.  On  fourth 
and  three  following  days  6000  units  each  time  subcutane- 
ously. On  forty-eighth  day  temperature  still  101°  to  102° 
F.,  patient  irritable  and  emaciated.     Will  probably  die. 

Child  4^4  years  old,  severe  attack.  On  twelfth  and 
following  five  days  6000  units  each  time.  Very  emaciated, 
hydrocephalus.     Will  doubtless  die. 

Child  of  12  years.  On  sixth  day  1500  units  intra- 
spinally,  on  seventh  day  12,000  subcutaneously.  On  fif- 
teenth day  patient  conscious.     Will  recover. 

Child  of  10  years,  mild  attack.  On  fifth  day  1500  units 
intraspinally,  on  seventh  day  same.  On  fourteenth  day 
patient  pretty  well,  with  acute  inflammation  of  right  knee. 

Of  th  21   cases  9  have  already  died. 

During  the  year  1904  we  had  25  cases  in  adults, 
15  =  57-6  per  cent,  proving  fatal;  23  in  children, 
10  =  43.5  per  cent,  ending  in  death.  From  January  1  to 
April  1,  1905,  we  admitted  36  cases.  Of  these  20  are  no 
longer  in  the  hospital,  11  children  and  5  adults  being  still 
here.  Two  of  the  1 1  children  received  no  antitoxin,  6  re- 
ceived intraspinal  injections  of  it  (on  the  average  1500 
units,  one  or  more  times),  in  3  it  was  injected  subcutane- 
ously. One  case  has  recovered,  another  is  nearly  well  but 
deaf,  a  third  nearly  well  but  with  acute  inflammation  of 
one  knee;  1  case  quickly  recovered  without  any  treatment, 
1  seems  to  be  improving  but  is  doubtful,  1  has  improved  but 
still  has  intermittent  pyrexia,  1  has  had  a  relapse,  2  are 
exceedingly  emaciated,  1  has  high  temperatures  which  in- 
termit, however,  1  has  a  low  temperature  with  all  the 
signs  of  chronic  inflammation.  Of  the  5  adults  remaining 
alive,   1   is  perfectly  well,  1   very  doubtful,  2  on  the  way 

116 


CEREBRO-SPINAL    MENINGITIS 

to  recovery,  1  is  much  better  but  occasionally  irrational 
and  may  recover. 

Of  5  children  leaving  the  hospital  'during  these  three 
months,  1  was  discharged  January  14th  with  deafness,  no 
antitoxin  had  been  administered;  1  discharged  cured  Jan- 
uary 20th,  no  antitoxin;  1  died  March  1st,  no  antitoxin; 
1  died  March  29th,  had  antitoxin;  1  died  April  2d,  had 
antitoxin. 

Only  1  of  the  15  adults  in  the  hospital  since  Jan- 
uary 1  st  has  been  cured,  without  antitoxin ;  4  died  with- 
out antitoxin;  10  died  in  spite  of  antitoxin  treatment.  In 
all  probability  our  cases  this  year  (1905)  will  show  a 
mortality  of  60   per  cent. 

Since  January  1st,  1904,  85  cases  have  been  admitted; 
l6  are  still  at  the  hospital,  69  have  passed  from  obser- 
vation. Of  these  25  died  during  1904,  3  were  taken  away 
uncured  and  their  termination  is  unknown,  17  (out  of  20) 
can  be  proved  dead — thus  42  deaths  out  of  66  cases, 
equivalent  to  64  per  cent.,  up  to  date.  Of  those  who  have 
remained  living  3  are  deaf  and  1  is  blind. 

Once  death  set  in  within  30  hours,  in  a  child  12  years 
old;  once  within  38  hours  from  the  onset  of  the  disease, 
in  a  child  of  3%  years.  In  the  latter  case  the  pupils 
were  unequal,  and  there  were  convulsions,  coma  and  a 
temperature  of  103°  to  109°  F.  Death  survened  in 
another  case  after  2  days,  while  in  still  another  after 
55  days.  Still  longer  periods  of  sickness  have  not  yet 
terminated  in  death,  the  patients  are  still  struggling.  A 
child  3  years  old  was  dismissed  after  55  days  with 
deafness;  one  of  10  years  was  discharged  cured  after  90 
days;  two  of  5  years  were  discharged  perfectly  cured  on 
the  69th  and  76th  day,  respectively,  one  of  8  years  on 
the  100th  day.  Thus,  of  100  patients  two-thirds  died 
and  several  were  crippled.  Whether  the  affected  nervous 
centre  of  those  who  have  recovered  will  ever  be  perfectly 
normal  is  uncertain.  Those  of  us  who  have  become  fa- 
miliar from  personal  observation  with  the  obstinacy  of 
the  disease  process,  will  probably  not  be  able  to  dispel 
their  doubts  as  to  the  completeness  of  the  recovery.  For 
me  there  is  nothing  more  sad  and  more  disheartening  than 

117 


DR.    JACOBI'S    WORKS 

a  hall  filled  with  cases  of  epidemic  cerebro-spinal  menin- 
gitis. 

PosTCRiPTUM,  May_,  1909- 

Nulla  dies  sine  tinea.  That  is  almost  literally  true  in 
regard  to  medicine^  whose  practical  benefits  are  appreciated 
by  everybody  except  the  hypocrites  or  fanatics  of  the 
"  antivivisection  "  creed.  The  hopelessness  of  the  victims 
of  the  meningococcus  is  no  longer  absolute  or  even  nearly 
absolute.  Simon  Flexner's  name  has  suddenly,  and  de- 
servedly, become  a  household  word  in  both  hemispheres. 
I  listened  to  him  recently  when  he  lectured  at  Baltimore 
before  the  Medical  and  Chirurgical  Faculty  of  Maryland, 
(May  14th  1909)-  He  was  as  modest  and  withal  hopeful 
as  always.  He  is  rather  doubtful  and  cautious  when  others 
are  joyful  and  enthusiastic;  but  he  cannot  disclaim  the 
beneficial  results  of  his  antimeningitis  serum.  Even  to-day 
cerebro-spinal  meningitis  is  amenable  to  treatment,  thanks 
to  Flexner,  and  many  who  formerly  would  have  died  of 
the  infection,  are  now  saved. 

When  Flexner  was  in  a  position  to  supply  patients  with 
his  serum,  the  New  York  epidemic  was  relenting.  That  is 
why  he  does  not  consider  our  local  experience  as  momentous 
or  conclusive,  but  prefers  to  reckon  with  the  bad  cases  of 
a  beginning  epidemic  only.  The  epidemics  of  the  middle 
West  have  been  grave,  but  were  decidedly  influenced  by 
the  use  of  the  serum.  Of  seven  cases  in  the  Jefferson,  Mo., 
barracks  only  two  died;  of  five  in  which  the  diagnosis  was 
made  early,  all  recovered  with  the  serum.  In  McKinney, 
Texas,  after  four  cases  had  died  in  a  single  family, 
five  other  cases,  who  could  be  supplied  with  the  Flexner 
serum,  recovered.  The  speaker  mentioned  three  recov- 
eries in  five  cases  occurring  in  the  practice  of  Dr.  Koplik. 
The  most  conclusive  results  have  been  obtained  in  the 
recent  epidemics  of  Europe,  where  the  diagnoses  were 
made  earlier  and  the  serum  treatment  resorted  to  in  due 
time.  England,  Scotland  and  Ireland  have  active  epi- 
demics, and  the  disease  is  decidedly  modified  by  the  serum. 
The.  former  mortality  of  75  per  cent,  has  been  reduced  to 
40  per  cent,  in  Edinburgh,  to  from  25  to  30  per  cent,  in 

118 


CEREBRO-SPINAL    MENINGITIS 

Belfast.  The  character  of  the  cases  has  changed;  the 
protracted  chronic  course  which  extended  over  several 
months,  ceased  abruptly  in  the  hospital  wards.  France  had 
a  severe  epidemic  of  two  or  three  months.  Netter  had 
fifty  cases.  Of  ten  children  under  two  years  of  age  that 
were  treated  with  Flexner's  serum,  he  lost  one.  Calmette 
treated  fourteen  soldiers  in  the  barracks  of  Lille.  One 
died.  Three  were  sick  outside  the  barracks  with  no  serum. 
They  all  died.  Roux  expresses  himself  as  being  greatly 
struck  with  the  results  of  serum  treatment.  And  as  we 
go  to  press  we  glean  from  the  Lancet  (May  15,  1909) 
that  the  epidemic  in  France,  which  is  now  on  the  decline, 
has  made  two  things  perfectly  plain:  the  one  is  that  the 
disease  is  extremely  contagious  and  the  other  that  the 
use  of  anti-meningococcic  serum  is  of  great  value.  The 
epidemic  in  the  garrison  at  Evreux,  which  M.  Vaillaire 
studied  with  particular  care,  showed  that  the  contagion 
spread  from  one  soldier  to  another  when  they  occupied  con- 
tiguous beds  in  the  same  room.  Some  reservists  who  had 
been  in  barracks  at  Evreux  and  who  had  been  sent  home 
when  the  epidemic  broke  out  carried  the  infection  with 
them  even  if  they  showed  no  signs  of  the  disease  them- 
selves. One  of  them,  who  was  quite  well,  infected  his 
wife  who  died;  another  infected  four  other  persons,  of 
whom  two  died.  Examination  of  the  troops  in  barracks 
showed  that  in  19  per  cent,  of  them  the  meningococcus 
was  present  in  the  naso-pharyngeal  mucous  membrane. 
Of  24  cases  treated  otherwise  than  by  serotherapy  l6 
died,  and  of  the  same  nmnber  of  cases  treated  with  the 
serum  only  four  died,  the  mortality  in  the  one  case  being 
66.6  per  cent,  and  in  the  other  l6.6  per  cent.  The  earlier 
that  the  serum  is  administered  the  better  are  the  results 
and  therefore  an  early  diagnosis  is  of  much  importance. 
The  world  does  move. 


119 


DIPHTHERIA:    ITS    SYMPTOMATOLOGY   AND 
TREATMENT 

INTRODUCTION 

Definition. — Diphtheria  is  a  specific,  infectious  and  con- 
tagious disease  characterized  principally  by  epithelial 
changes  and  by  the  exudation  of  fibrin  on  or  in  mucous 
membranes,  or  on  the  surface  of  wounds,  or  in  the  de- 
nuded rete  Malpighi,  constituting  the  so-called  pseudomem- 
branes.  These  are  mostly  found  on  the  accessible  mucous 
membranes  of  the  digestive  and  respiratory  organs.  Their 
morphological  structure  in  the  throat,  nares,  larynx,  and 
other  places  is  identical,  but  they  have  been  studied  chiefly 
in  the  throat,  where  they  are  most  frequently  found.  They 
consist  of  finely  reticulated  fibrin  holding  exudate  cells, 
leucocytes,  some  few  erythrocytes,  and  characteristic 
microbes.  When  they  are  superficial,  it  is  the  epithelial 
protoplasm  which  is  thus  transformed;  when  they  are  deep- 
seated  with  a  tendency  to  necrosis,  ulceration,  and  finally 
(if  recovery  take  place)  cicatrization,  it  is  the  fibrillar 
basic  substance  of  the  connective  tissue,  chiefly  of  the 
mucous  membrane,  sometimes  also  of  the  submucous  and 
deeper  structures.  This  view,  which  underlies  the  discus- 
sions of  all  my  contributions  to  the  subject  of  diphtheria 
since  I860,  has  lately  been  again  most  forcibly  demon- 
strated by  Baumgarten  {Berliner  klinische  Wochenschrift, 
Nos.  31  and  32,  1897). 

History — Diphtheria  has  been  epidemic  on  the  Atlantic 
coast  of  North  America  since  1857.  The  disease  was  al- 
most unknown  at  that  time — my  paper  on  diphtheria  and 
diphtheritic  aff"ections  in  the  American  Medical  Times  of 
August  nth  and  18th,  I860,  was  the  first  (or  among  the 
first?)  of  those  which  were  written  on  the  subject  in 
our  part  of  the  country  during  the  last  half  century — but 

121 


DR.    JACOBI'S    WORKS 

the  literature  has  since  grown  immensely.  It  was  very 
extensive  when  I  collected  it  in  my  essay  on  "  Diphtheria  " 
in  the  second  volume  of  Gerhardt's  "  Handbuch  der  Kin- 
derkrankheiten "  (1877).  It  soon  took  such  dimensions 
that  neither  in  my  "  Treatise  on  Diphtheria  "  (New  York, 
1880)  nor  in  Pepper's  "American  System  of  Medicine" 
(Vol.  I.,  1885),  nor  in  other  publications  did  I  do  more 
than  refer  to  authorities  for  the  elucidation  of  particular 
points.  For  many  years  past  it  has  been  the  etiology  of 
the  disease  which  has  created  a  literature  of  its  own; 
so  has  that  part  of  the  subject  which  treats  of  antitoxin 
and  of  intubation.  Symptomatology  in  all  its  bearings 
and  morphology  have  not  received  many  valuable  addi- 
tions; for  clinical  observations,  when  correct  and  correctly 
reported,  are  not  "  subject  to  change  and  at  the  mercy  of 
unknown  factors,"  as  a  great  experimenter  has  lately  said. 
On  the  contrary^  the  vast  amount  of  labor,  as  exhibited  in 
endless  journal  articles  and  books  on  special  topics,  which 
has  to  be  spent  on  the  establishment,  verification,  or  refu- 
tation of  a  single  fact  in  bacteriology,  does  not  prove 
that  "  the  results  obtained  by  experimentation  in  the  labora- 
tory are  unambiguous  "  to  the  exclusion  of  clinical  em- 
piricism. Thus  it  happens  that  on  the  following  pages  I 
shall  frequently  repeat  statements  (many  now  out  of 
print)  which  have  been  found  correct  in  the  course  of  time, 
and  give  advice  that  will  still  be  found  serviceable  though 
it  was  offered  decades  ago. 

Virchow  distinguished  between  croupous  and  diphtheritic 
membranes.  In  his  opinion  the  former  was  fibrinous  with 
cell  proliferations,  epithelia,  and  pus,  and  was  superficial 
on  top  of  the  mucous  membrane ;  the  latter  was  an  ex- 
udation into  the  tissue  of  an  amorphous,  dense,  and  coagu- 
lated fibrin  which  did  not  always  injure  or  implicate  the 
surface  epithelium,  but  would  necrose  the  deeper  tissue 
and  give  rise  to  ulceration  before  healing.  But  he  ad- 
mitted that  complications  between  the  two  were  very  com- 
mon indeed.  Weigert  and  Cohnheim  were  of  the  same 
opinion  as  far  as  the  morphological  condition  and  localiza- 
tion of  the  membranes  were  concerned ;  the  essential  process 
according  to  them  was  a  combination  of  necrosis  and  in- 

122 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

flammation,  and  their  causes,  after  Recklinghausen  and 
NassilofF  had  assumed  the  primary  change  to  be  a  microbic 
invasion,  were  bacteria  and  toxins. 

According  to  Wagner  the  only  difference  between  croup 
and  diphtheria  membranes  was  the  fine  structure  of  and 
the  admixture  of  pus  cells  to  the  former.  Both  of  them 
had  their  origin  in  the  epithelium,  while  Buhl  looked  for 
it  in  the  mucous  membrane  itself,  in  the  cells  of  which  nu- 
clear or  cystoid  proliferations  took  place. 

I  cannot  detect  much  difference  in  the  theories  which 
have  since  been  brought  forward,  for  instance,  in  those 
of  Oertel  or  of  Heubner.  The  question  is  always  one  of 
degeneration  of  epithelia,  of  the  presence  of  leucocytes, 
an  exudation  of  fibrin,  more  or  less  admixture  of  blood, 
of  hyaline  masses,  and  of  new  formation  of  more  or 
fewer  round  cells  in  different  localities.  Oertel  comes  to 
the  conclusion  that,  after  all,  the  localization  of  the  process 
is  the  final  cause  of  the  form  and  appearance  of  the 
pseudomembrane.  Why  he  should  make  the  effort  of  sug- 
gesting the  differentiation  between  a  primary  and  a  sec- 
ondary membrane,  the  former  consisting  of  direct  surface 
deposits,  and  the  latter  of  membranous  deposits  in  the  tis- 
sue which  are  produced  by  the  presence  of  other  surface 
deposits  in  the  neighborhood,  is  not  quite  intelligible  ex- 
cept on  the  score  of  "  completeness." 

For  some  years  it  has  become  customary  to  distinguish 
between  those  pseudomembranes  which  are  caused,  or  ac- 
companied, by  the  Klebs-Lceffler  bacillus,  and  those  which 
contain  the  "  pseudobacillus  "  or  staphylococci  and  princi- 
pally streptococci.  That  these  microbes  do  not  establish 
any  disease  by  their  mere  presence,  that  on  the  contrary 
they  are  met  with  to  an  indefinite  degree  in  the  mouths 
and  throats  of  the  healthy,  is  well  understood.  That  they 
may  be  considered  pathological,  or  pathogenic,  the  presence 
of  pseudomembranes  and  the  presence  of  the  microbes 
in  the  pseudomembranes  in  some  stage  of  development  is 
required.  The  Klebs-Loeffler  bacillus  is,  however,  not  al- 
ways found  in  every  stage  of  the  illness;  it  appears  to 
perish  quite  often  towards  the  maceration  period.  When 
found  it  is  located  in  the  superficial  layers  of  the  pseudo- 

123 


DR.    JACOBI'S    WORKS 

membrane  only,  and  not  throughout  its  whole  thickness; 
the  coccus,  however,  pervades  its  whole  substance,  usually 
in  greater  numbers  in  the  deeper  laj-ers.  To  explain  the 
absence  of  Klebs-Loeffler  bacilli  from  these,  it  is  assumed 
that  they  are  destroyed  by  other  microbes.  Still  they  are 
credited — in  the  same  way  in  which  they  can  be  proven 
to  do  so  in  the  laboratory — with  evolving  the  toxin  which 
gives  rise  to  all  the  symptoms  and  dangers  of  certain 
forms  of  constitutional  diphtheria. 

Pseudomembranes  containing  Klebs-Lceffler  bacilli  are 
called  by  almost  universal  agreement  diphtheritic,  those 
with  pseudobacilli  and  cocci  pseudodiphtheritic.  Local 
diphtheria  ("  diphtheritis  "),  constitutional  diphtheritic 
infection,  and  diphtheritic  sepsis  are  different  degrees  of 
the  same  disease.  The  first  may  run  a  fairly  mild  course, 
or  be  the  initial  stage  of  the  second  and  (or)  third.  Those 
cases  which  present  both  bacilli  and  streptococci  in  their 
membrane  are  called  cases  of  mixed  infection.  It  has  been 
claimed  that  cases  of  the  second  class,  that  of  streptococcus 
infection,  are  of  little  virulence  and  attended  with  but 
little  danger.  This  opinion  leads  to  cruel  mistakes  in 
management,  both  by  boards  of  health  and  by  such  medical 
men  as  are  influenced  by  them.  For  not  only  are  many 
uncomplicated  cases  very  grave,  but  the  mixed  infections 
are  the  very  worst  forms  met  with  in  practice.  More- 
over, the  streptococcus  cases  are  contagious,  contrary 
opinions  notwithstanding.  Still,  it  is  important  to  mention 
at  once  that  accurate  differentiation  has  its  great  practical 
value,  for  the  reason  that  it  is  solely  the  bacillary  variety 
that  can  be  influenced  by  the  diphtheria  antitoxin  (see 
below). 

The  part  played  by  microbes  in  diphtheria  is  not  yet 
absolutely  clear.  The  Klebs-Loeffler  diphtheria  bacillus 
and  a  similar  bacillus  that  is  not  virulent  are  found  in  dia- 
betic and  in  common  tuberculous  lungs,  in  noma,  in  em- 
pyema, on  chancres,  in  ozaena,  and  in  vaccinia  pustules. 
It  is  claimed  that  there  are  differences  between  the  two; 
the  pseudodiphtheria  bacillus  is  described  as  plumper, 
shorter,  and  more  uniform  than  the  genuine  Klebs-Loeffler, 
but  this  difference  is  not  so  striking  as  not  to  be  denied 

1^4 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

by  many;  nor  is  there  unanimity  among  different  examiners 
in  regard  to  other  differences.  Many  go  so  far  as  to 
deny  the  possibility  of  a  differentiation.  Loeffler  himself 
has  finally  come  to  the  conclusion,  lately  expressed  in  the 
Congress  of  Hygiene  at  Madrid,  that  the  genuine  diph- 
theria bacillus  cannot  be  diagnosticated  in  any  other  way 
than  by  its  power  to  generate  the  diphtheria  toxin  and 
by  the  influence  the  diphtheria  antitoxin  has  on  the  bacil- 
lus, or  rather  on  the  disease.  Thus  it  is  acknowledged 
that  there  are  saprophytes  which  can  be  distinguished  from 
genuine  diphtheria  bacilli  by  nothing  but  the  absence  of 
virulence. 

Another  authority,  C.  Fraenkel,  admits  that  the  degree 
of  virulence  is  so  variable  that  it  cannot  be  employed  for 
differentiation.  A  very  virulent  bacillus  loses  its  virulence 
by  a  change  of  the  culture  medium,  and  feebly  virulent 
bacilli  are  rendered  highly  so  by  adding  streptococci 
(Roux  and  Yersin).  Moreover  Trumpp  mixed  "  pseudo- 
bacilli  "  found  in  the  pus  of  empyema  with  diphtheria 
toxin  (not  bacilli),  made  new  cultures,  and  obtained  very 
virulent  bacilli;  and  he  found  that  repeated  injections  of 
pseudobacilli  would  finally  kill  like  genuine  bacilli. 

F.  Schanz  (Deutsche  medicinische  Wochenschrift,  No. 
37,  1898),  who  lately  elaborated  these  considerations  and 
facts,  adds  the  pertinent  remark  that  a  bacillus  which  is 
so  frequently  found  on  the  mucous  membranes  of  the 
healthy  or  of  the  convalescent  without  the  presence  of 
diphtheria,  appears  to  play  only  an  inferior  and  secondary 
part  in  the  development  of  disease.  He  thinks  that  the 
bacillus  increases  on  inflamed  surfaces  and  attains  the 
power  of  producing  a  toxin  in  the  membranous  exudation 
only;  that  it  is  this  toxin  which  adds  to  the  danger  of 
the  disease,  and  that  the  presence  of  streptococci  increases 
its  peril;  and  that  it  is  not  impossible  at  all  to  assume 
that  diphtheria  originates  from  an  unknown  cause  of  its 
own,  but  becomes  more  virulent  by  the  action  of  the 
toxin  of  the  Klebs-Loefller  bacillus  (with  or  without  the 
aid  of  streptococci),  whose  effect  may  be  destroyed  by 
the  diphtheria   antitoxin. 

Evidently  the  question  of  the  origin  (single  or  multiple) 

125 


DR.    JACOBI'S    WORKS 

of  diphtheria  does  not  seem  to  be  settled  to  the  satisfac- 
tion of  all.  According  to  Theobald  Smith  (Boston  Medi- 
cal and  Surgical  Journal,  August  25th,  1898)  "it  is  only 
clinicians  whose  voices  are  sometimes  raised  against  the 
Klebs-Lceffler  bacillus  as  the  chief  cause  of  diphtheria  " ; 
but  Loeffler  himself,  and  C.  Fraenkel,  and  others,  equally 
conscientious,  are  more  careful  than  formerly  in  express- 
ing positive  views  and  are  less  averse  to  retracing  their 
steps. 

There  are  other  questions  in  connection  with  diphtheria 
which  seem  to  be  positively  settled,  for  instance,  that  of 
the  morphology  of  the  pseudomembranes.  In  Gerhardt's 
"  Handbuch  "  and  in  my  "  Treatise  "  I  studied  the  sub- 
ject with  a  view  to  elucidate  the  differences  in  the  con- 
dition of  morphologically  identical  pseudomembranes  when 
found  in  different  locations.^ 

Morphology  of  Pseudomembranes. — Twenty-five  years 
ago  Trendelenburg  infected  the  trachea  of  a  rabbit  with 
diphtheritic  deposits  which  he  had  removed  from  the 
pharynx  and  tonsils,  in  the  tissues  of  which  they  were 
deeply  and  firmly  imbedded.  The  new  deposits,  however, 
did  not  take  so  deep  and  firm  a  hold  on  the  tissues  as 
the  original  ones,  but  adhered  lightly  to  the  mucous 
membrane  of  the  trachea  to  which  they  had  been  trans- 
planted. This  and  many  other  similar  facts  cannot  be 
explained  by  the  nature  of  the  pseudomembrane,  but  by 
the  histological  character  of  the  mucous  membrane  only, 
which  varies  with  the  locality.  Its  different  elements, 
viz.,  the  epithelium,  basement  membrane,  connective  tissue 
interwoven  with  elastic  fibres,  with  blood  vessels,  with 
nerves  from  the  cerebrospinal  and  sympathetic  systems, 
and  frequently  with  spindle  cells,  and  the  papillae  ducts 
of  numberless  glands,  all  influence  the  pathological  process 
going  on  upon  the  surface. 

The  mucous  membrane   of   the   mouth  contains   a  large 

1  These  bacteriological  statements  and  the  following  referring 
to  the  morphology  of  pseudomembranes  are  considered  by  the 
author  necessary  for  the  explanation  of  much  that  he  has  to  say 
on   symptomatologj'   and   treatment. 

126 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

number  of  elastic  fibres  mixed  with  cellular  tissue  and 
covered  by  a  thick  coat  of  pavement  epithelium;  its  up- 
permost layer  contains  flat  cells,  the  second  a  larger  quan- 
tity of  polygonal  cells,  and  the  lowest  oval  ones  which 
assume  a  perpendicular  relation  to  the  mucous  membrane. 
From  the  mucous  membrane  a  number  of  papillae  extend 
into  the  epithelium,  and  in  this  respect  they  resemble 
the  papillae  of  the  skin.  Acinous  muciparous  glands  are 
frequent,  and  most  numerous  in  the  anterior  aspect  of  the 
soft  palate.  Lymph  vessels  are  very  numerous  in  the  lips, 
tongue,  uvula,  soft  palate,  anterior  and  posterior  pillars 
of  the  soft  palate,  and  cheeks.  The  uvula  contains  so 
many  that,  if  they  be  injected  its  circumference  is  in- 
creased two  or  three  fold.  They  empty  into  the  deep 
facial  lymph  bodies  to  which  they  communicate  diph- 
theria as  well  as  other  infections.  The  lymphatics  of  the 
tongue  are  in  intimate  connection  with  the  upper  layer  of 
the  deep  cervical,  those  of  the  floor  of  the  mouth  and  many 
from  the  tongue  connect  with  the  submaxillary  lymph 
bodies.  The  efferent  vessels  empty  their  contents  into  the 
superior  jugular  lymph  nodes,  situated  in  the  trigonum 
cervicale  superius,  and  finally  into  the  fifteen  or  twenty 
inferior  jugular  (or  supraclavicular)  nodes  which  with 
numerous  anastomoses  form  the  jugular  lymphatic  plexus. 
The  tonsils  are  conglomerations  of  an  indefinite  number  of 
follicular  bodies,  each  of  which  has  a  thick  capsule  which 
is  of  irregular  shape,  and  consists  of  connective  tissue 
lined  by  mucous  membrane  and  pavement  epithelium.  The 
connective  tissue  contains  a  number  of  closed  follicles, 
each  inclosing  numerous  lymph  corpuscles.  The  follicles 
have  been  considered  identical  with,  or  analogous  to,  the 
lymph  bodies ;  this  assumption  is  purely  problematical,  since 
it  has  not  been  possible  thus  far  to  verify  the  existence 
of  afferent  or  efferent  ducts.  The  practical  deduction 
from  this  is  that  the  tonsils  have  little  connection  with  the 
lymphatic  system,  and  that  a  disease  limited  to  a  tonsil  is 
not  liable  to  infect  the  organism  immediately  and  intensely. 
The  mucous  membrane  of  the  nasal  cavities  is  of  vary- 
ing degrees   of   thickness;   it   consists   of   connective-tissue 

127 


DR.    JACOBI'S    WORKS 

fibres  with  numerous  nuclei,  is  free  from  elastic  fibres, 
but  is  supplied  with  a  large  number  of  nerves  and  an 
abundance  of  blood-vessels ;  the  Schneiderian  membrane 
possesses  in  fact  a  larger  number  of  blood-vessels  than 
do  most  of  the  other  mucous  membranes.  That  is  why, 
with  its  submucous  tissue,  it  frequently  is  the  seat  of 
swellings  and  hemorrhages,  as  well  in  diseases  of  distant 
organs  which  give  rise  to  venous  stagnation,  as  from  the 
slightest  local  provocation.  The  inner  surface  of  the  car- 
tilaginous portion  is  lined  with  pavement  epithelium;  the 
lower  region  of  the  real  nasal  cavities,  the  so-called  respir- 
atory portion,  through  its  whole  length  supplied  with 
branches  of  the  trifacial  nerve,  is  lined  with  cj^lindrical 
epithelium  and  contains  a  large  number  of  mucous  glands. 
The  upper  or  so-called  olfactory  portion  is  lined  with  cili- 
ated epithelium,  and  is  supplied,  according  to  Todd  and 
Bowman,  with  long,  straight,  tubular  glands.  Here  the 
lymphatics  are  but  poorly  developed,  while  in  the  inferior 
portion  they  are  very  numerous ;  all  their  openings  com- 
municate directly  with  the  deep  facial  and  posterior  sub- 
maxillary lymph  bodies.  Thus  it  can  be  readily  under- 
stood why  the  slightest  irritation,  by  a  nasal  catarrh  for 
instance,  in  a  child  produces  a  temporary  or  permanent 
swelling  of  the  lymph  nodes  and  why  the  nares  should 
necessarily,  by  their  multitude  of  toxin  absorbing  lymph 
follicles  and  ducts,  be  among  the  most  dangerous  localiza- 
tions  of  diphtheria. 

The  epiglottis  carries  a  layer  of  pavement  epithelium  of 
0.2  mm.  in  thickness  on  its  anterior  superior  surface,  that 
on  its  posterior  surface  being  from  0.06  to  0.1  mm.  in 
thickness.  The  superficial  layer  consists  of  spheroidal  or 
polygonal  cells,  the  deeper  is  of  cylindrical  cells  arranged 
perpendicularly  to  the  surface.  Near  the  insertion  of  the 
epiglottis,  the  polygonal  cells  disappear,  the  cylindrical 
occupy  the  surface,  and  are  furnished  with  cilia  0.005  mm. 
in  thickness.  Beneath  these  there  are  round  and  oval 
cells  in  considerable  number,  so  that  the  whole  epithelial 
coating  has  a  thickness  of  0.5  mm.  Ciliated  epithelium  is 
also  found  on  the  false  vocal  cords  and  in  the  ventricles 
of  the  larynx.     Polygonal  pavement  epithelium  forms  the 

128 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

covering  of  the  posterior  surface  of  the  pharynx,  of  the 
aryepiglottic  folds,  where  the  mucous  membrane  possesses, 
in  addition,  a  heavy  and  lax  submucous  tissue,  and  of  the 
true  vocal  cords.  As  one  approaches  the  laryngeal  ven- 
tricles and  trachea,  the  previous  coating  is  replaced  by 
delicate  ciliated  epithelium.  The  mucous  membrane  in 
the  neighborhood  of  the  laryngeal  ventricles  is  itself  very 
loosely  attached,  exceedingly  thin,  and  frequently  thrown 
into  folds  on  the  vocal  cords.  Acinous  glands  are  here 
abundant,  being  fifteen  to  twenty  to  the  square  centimetre, 
and  arranged  lengthwise.  Around  the  ventricles  they  are 
very  numerous,  and  their  outlets  are  lined  with  cylindrical, 
rarely  with  ciliated  epithelium.  The  true  vocal  cords  are 
not  supplied  with  glands  of  any  kind. 

The  acinous  glands  have  no  lymphatics  leading  into 
them,  but  the  latter  may  be  seen  in  other  parts  of  the 
mucous  membrane  of  the  larynx  and  in  the  submucous 
tissue.  In  fact,  they  are  both  large  and  numerous,  and 
have  the  general  character  of  lymphatics,  as  regards  the 
endothelium  in  particular.  In  the  epiglottis  of  the  new- 
born they  form  but  a  single  layer,  in  the  larynx  and  trachea 
two  layers,  and  in  certain  parts  which  are  covered  by  a 
considerable  amount  of  submucous  tissue,  there  are  even 
three  layers.  Innermost  the  lymphatics  are  arranged  per- 
pendicularly to  the  surface;  outermost,  horizontally. 

The  comparative  absence  or  scantiness  of  lymphatics 
over  the  larger  part  of  the  surface  accounts  for  the  ab- 
sence of  constitutional  symptoms  in  localized  laryngeal 
diphtheria  ("  pseudomembranous  croup  "),  and  the  exten- 
sive layer  of  pavement  epithelium  accounts  for  the  per- 
sistence of  membranes  both  on  the  epiglottis  and  in  some 
parts  of  the  larynx. 

The  mucous  membrane  of  the  trachea  and  bronchi  con- 
tains more  elastic  than  fibrous  tissue,  a  moderate  amount 
of  lymph  vessels,  no  lymph  bodies,  but  an  abundance  of 
mucous  glands,  and  is  freely  supplied  with  ciliated  epithe- 
lium. 

Among  all  the  tissues  and  organs  thus  far  spoken  of, 
the  elastic  tissue,  which  is  an  important  element  in  the 
formation  of  connective  tissue,  is  least  affected  by  chemical 

129 


DR.    JACOBI'S    WORKS 

or  organic  influences.  It  is  not  present  in  the  mucous 
membrane  of  the  nose,  but  to  a  considerable  amount  in 
the  buccal  cavity,  is  very  abundant  in  the  walls  of  the 
lymph  follicles  of  the  tonsils,  and  predominates  in  the 
trachea.  The  influence  of  these  anatomical  conditions  on 
the  diphtheritic  process  must  be  very  marked.  It  can 
easily  be  demonstrated  that  where  the  elastic  tissue  is  pre- 
vailing, a  resistance  to  diphtheritic  impregnation  is  main-, 
tained  for  a  long  time,  but  when  it  has  been  forced  to 
yield,  there  is  a  corresponding  resistance  to  recovery. 

It  is  the  pavement  epithelium  that  gives  the  easiest  foot- 
hold to  diphtheritic  membrane.  Where  it  is  most  abun- 
dant, the  diphtheritic  process  can  best  settle  and  develop. 
That  is  why  the  tonsils,  not  from  their  prominent  situa- 
tion alone,  but  from  the  character  of  their  surface  also, 
are  favorable  to  the  reception  and  further  development 
of  an  infection,  and  their  elastic  and  connective  fibres, 
when  at  last  aff'ected,  are  apt  to  harbor  the  process  a  long 
time.  Ciliated  epithelium,  on  the  other  hand,  is  not  liable 
to  be  invaded.  It  occupies  a  higher  rank  in  the  scale  of 
animal  formation,  and  has  a  more  complex  function  and  a 
greater  power  of  resistance;  besides,  it  expels  bj'  its  con- 
stant movements  microscopic  foreign  bodies. 

The  presence  of  a  large  number  of  mucous  glands  im- 
pedes, as  a  rule,  by  the  presence  of  the  normal  secretion, 
an  extensive  destructive  action  upon  the  tissues.  The  se- 
creted mucus  assists  in  removing  epithelial  masses,  and  even 
fibrinous  exudations,  from  the  surface.  The  underlying 
tissues  themselves  do  not  always  take  an  active  or  prom- 
inent part  in  the  process ;  the  serum  of  the  mucus  pene- 
trates the  parts  which  are  the  seat  of  morbid  deposits. 
and  tends  to  predispose  the  latter  toward  maceration,  and 
the  mucous  secretion  raises  mechanically  the  superjacent 
deposits  from  their  bed.  Thus  it  is  that  the  deposits  in 
the  respiratory  portion  of  the  nasal  cavities  are  frequently 
cast  off  through  the  nostrils,  probably  because  they  have 
been  produced  in  excess;  and  in  £l  similar  manner,  the 
membranes  that  have  formed  in  the  trachea  are  ejected  in 
a  semisolid  condition  through  a  newly  made  tracheotomic, 
or  even  the  natural,  outlet.     The  large  number  of  mucous 

130 


DIPHTHERIA:     SYMPTOMS    AND     TREATMENT 

glands  in  a  part  of  the  larj^nx  and  in  the  whole  trachea 
is  unquestionably  the  reason  v>'hj  the  lymphatic  vessels 
of  the  mucous  membrane,  even  where  they  are  present  in 
large  numbers,  are  not  influenced  by  the  overlying  loosened 
masses,  and  will  not  absorb;  hence  laryngeal  anl  tracheal 
forms  of  diphtheria  Imve  a  decidedly  local  character,  and 
are  mostly  devoid  of  constitutional  sj'mptoms. 

The  vocal  cords  form  the  borders  of  the  narrowest  aper- 
ture of  the  air  passages ;  they  detain  or  retain  foreign 
bodies,  whether  malignant  or  otherwise;  they  are  covered 
with  pavement  epithelium  which,  as  has  been  remarked, 
is  the  principal  resting  and  breeding  place  of  the  diph- 
theritic affection.  They  have  no  defence  furnished  by 
muciparous  follicles,  and  therefore  if  there  is  any  part 
which  is  predisposed  to  a  local  diphtheritic  infection  it  is 
certainly  the  vocal  cords.  That  is  why  in  the  beginning 
of  an  epidemic  of  diphtheria,  or  when  it  is  dying  out, 
a  local  diphtheritic  infection  can  still  take  place,  and  indi- 
7idual  cases  occur  now  and  then  with  an  almost  insignifi- 
cant power  of  infection.  Such  occurrences  took  place 
previous  to  the  ubiquity  of  diphtheria  forty  years  ago, 
and  are  still  met  with  under  the  same  conditions,  giving 
rise  to  the  so-called  sporadic  membranous  croup. 

On  the  other  hand,  the  absence  of  acinous  glands  on  the 
vocal  cords  must  serve  to  a  certain  degree  as  a  guard 
against  the  disease.  Dry,  atrophic,  but  at  the  same  time 
uninjured  and  smooth  conditions  of  the  mucous  membrane 
of  the  fauces  tend  to  ward  off  an  attack  of  diphtheria. 
A  more  or  less  moist  or  viscid  condition  of  the  surface  is 
necessary  in  order  that  the  infecting  material  may  cling 
thereto.  The  comparative  dryness  of  the  vocal  cords, 
however,  considered  by  the  side  of  the  perpetually  moist 
and  uneven  surface  of  the  pharynx,  would  not  appear  so 
favorable  to  the  deposition  of  foreign  infectious  elements. 
Thus  there  are  certain  conditions  predisposing  to,  others 
antagonizing  infection.  They  demonstrate,  however,  why 
laryngeal  croup  is  more  frequent  in  winter  than  in  sum- 
mer, in  direct  proportion  to  the  greater  frequency  of  laryn- 
geal catarrh  in  winter  than  in  summer.  Diphtheritic  mem- 
branes on  the  vocal  cords  are  not  easily  cast  oflT,  for  there 

131 


DR.    JACOBI'S    WORKS 

are  no  subjacent  muciparous  glands  whose  secretion  could 
wash  them  away.  No  general  infection  can  arise  from 
them^  for  they  have  no  lymphatic  vessels  which  could 
serve  as  carriers  of  the  poison;  furthermore,  suffocation 
from  a  local  cause  occurs  too  early  to  enable  the  few 
neighboring  lymphatics  to  absorb  and  transport  the  toxin 
elsewhere,  in  case  the  deposits  should  finally  become  mac- 
erated. 

The  comparative  absence  of  the  lymphatics  and  the 
paucity  of  blood-vessels  explain  why  diphtheria  of  the 
tonsils  has  so  mild  a  character.  The  large  number  and 
size  of,  as  well  as  the  direct  communication  of  the  lym- 
phatic ducts  of  the  Schneiderian  mucous  membrane  with 
the  lymphatic  glands  of  the  neck  account  for  the  dangerous 
character  of  diphtheria  of  the  nose.  However,  direct  in- 
fection, i.e.,  the  absorption  of  the  poison  into  the  body,  is 
not  always  dependent  on  the  lymphatics,  for  they  have 
occasionally  neither  enough  time  nor  the  opportunity  to 
use  their  power.  For  instance,  in  those  cases  of  diphtheria 
of  the  nose  in  which  early  and  slight  epistaxis  occurred, 
the  poison  appears  to  have  been  absorbed  directly  into  the 
blood-vessels.  Then  we  fail  to  observe  the  ordinary  swell- 
ing of  the  neighboring  glands  of  the  neck,  but  the  general 
symptoms  are  very  rapidly  developed.  Usually,  however, 
infection  results  through  the  lymphatics.  The  fluid  con- 
tents of  the  tissues,  or  such  particles  or  elements  as  are 
suspended  therein,  be  they  of  a  gaseous,  chemical,  or  para- 
sitic nature,  are  conducted  to  the  lymph  nodes  and  into 
the  circulation.  There  may  be,  however,  two  impediments 
in  the  current.  In  the  first  place,  the  foreign  material 
may  be  present  in  too  large  an  amount  to  circulate  with 
ease;  the  result  will  be  stagnation  and  consequent  irrita- 
tion, either  in  the  fascia  propria  or  in  the  substance  of 
the  lymph  nodes.  By  pressure,  the  capillary  circulation 
becomes  interfered  with,  proliferation  ensues,  the  circu- 
lating lymph  mingles  with  the  white  corpuscles  from  the 
lymph  spaces,  and  the  result  is  an  abscess  in  the  intra- 
or  periglandular  tissue.  Or  the  foreign  material  is  re- 
tained in  the  interior  of  the  fascias,  in  the  connective 
tissue,  or  in  the  dilated  lymph  vessels  of  the  cortical  sub- 

182 


DIPHTHERIA:    SYMPTOMS    AND    TREATMENT 

stance.  Thus  fluids  injected  into  the  cortical  substance 
have  been  found  collected  in  the  external  portions  of  the 
lymph  nodes,  where  it  was  impossible  for  them  to  be 
carried  into  the  circulation.  Hence  the  lymph  nodes  may 
serve  as  the  receptacle  of  noxious  elements  which  have  cir- 
culated in  the  lymph  current,  with  or  without  danger  to  the 
integrity  of  its  tissues.  In  this  manner  a  second  attack  of 
diphtheria  may  often  find  its  explanation  in  the  absorption 
of  stowed-away  poison ;  as  we  see  in  the  case  of  syphilitic  or 
other  infections,  which  may  either  be  stored  in  the  lymph 
body  unchanged  and  inactive,  or  if  their  presence  prove  ir- 
ritating, give  rise  to  speedy  suppuration,  and  even  elimina- 
tion, provided  the  abscess  be  opened  sufficiently  and  early. 

Dissemination  of  Diphtheria. — Diphtheria  is  a  conta- 
gious disease.  It  is  usually  transmitted  from  the  sick  to 
the  well  by  the  moist  or  dry  discharges  from  the  nose  and 
throat  of  the  sick  person.  This  transmission  may  take 
place  directly  or  indirectly  in  so  many  ways  that  is  is  not 
always  possible  to  trace  an  individual  case  to  its  source.  It 
is  the  multiplicity  of  mostly  unknown  modes  of  transmis- 
sion which  confuses  and  bewilders.  The  vulnerability  of 
the  young  mucous  membrane,  the  frequency  of  nasal  and 
pharyngeal  catarrh,  the  narrowness  of  the  nose,  the  large 
size  and  softness  of  the  tonsils,  the  frequent  fermentation 
of  food  in  the  mouth,  the  sucking  of  the  soiled  little  fin- 
gers, together  with  the  influence  of  family  disposition, 
which  is  more  powerful  in  the  young,  the  constant  inter- 
course of  children  with  each  other  in  large  families  and 
in  densely  populated  houses  and  districts,  in  schools  and 
on  playgrounds,  the  possibly  long  period  of  incubation 
during  which  the  disease  is  contagious  though  giving  rise 
to  no  symptoms,  act  as  just  so  many  predisposing  causes 
of  contagion ;  and  the  large  number  and  size  of  the  lym- 
phatics in  the  young  render  every  attack  so  much  the  more 
dangerous. 

The  very  facts  that  diphtheria  need  not  always  be  of  the 
same  type;  that  many  cases  of  lacunar  or  follicular  amyg- 
dalitis ("  tonsillitis  ")  are  diphtheritic — that  there  are  as 
many  cases  out  of  bed  and  out  of  doors  as  in  bed  and  in- 
doors;   that,    particularly    in    adults,    diphtheria    may   last 

133 


DR.    JACOBI'S    WORKS 

long  and  give  rise  to  but  few  embarrassing  symptoms,  and 
that  a  mild  case  of  diphtheria  may,  by  contagion,  produce 
very  serious  ones,  render  contagion  by  nursery  maids  and 
other  domestics,  by  teachers,  seamstresses,  sick-nurses, 
workmen,  factory  girls,  shopkeepers,  barbers,  and  all  other 
persons  mingling  with  the  many  extremely  easy.  The  vi- 
tality of  the  diphtheria  germs  is  persistent,  as  is  well 
known,  and  may  extend  over  years.  They  cling  to  solid 
and  semisolid  bodies,  are  imported  in  milk,  cling  to  walls 
and  floors,  to  toys,  to  curtains,  towels,  clothing,  and  bed- 
ding which  is  so  often  kindly  donated  to  the  poor  by  the 
benevolent  well-to-do  when  they  wish  to  get  rid  of  their 
own  dangers.  They  stick  to  omnibus  and  carriage  cushions, 
to  car  seats,  to  the  either  ready  or  custom  made  coat  on 
one's  shoulders  near  which  one's  baby  will  nestle — the 
very  coat  that  is  sold  in  Broadway  palaces  after  it  has 
been  made  in  the  pest-stricken  tenement  sweating  shop. 
The  very  restlessness  of  our  people,  the  frequency  of 
moving  into  unknown  and  often  infected  quarters,  is  an- 
other cause  of  doubling  the  number  of  cases.  There  can 
be  no  doubt,  besides,  that  many  animals — horses,  chickens, 
cows — have  and  spread  diphtheria.  Thus  it  appears  that 
we  ought  to  think  twice,  and  indeed  many  times,  before 
admitting  among  the  causes  of  diphtheria  new  factors 
which  cannot  be  proved. 

"  No  contagion  could  be  traced."  That  is  the  introduc- 
tion to  every  wild  and  unproven  theory  of  indigenous 
spontaneous  generation.  When  a  case  of  cholera  breaks 
out  in  a  village  a  thousand  miles  away  from  the  coast,  is 
there  anybody  in  our  time  who  looks  after  chemical  poison 
in  a  well  or  filth  on  the  roofs?  We  look  for  direct  or  in- 
direct contagion  from  a  tangible  source.  Why  not  so  in 
diphtheria .''  In  the  New  York  Medical  Journal  of  Sep- 
tember 27th,  1886,  I  quoted  from  Isambert  the  case  of 
a  medical  assistant  who  had  nasal  diphtheria  many  months, 
and  then  travelled  half  a  year  to  get  rid  of  the  last 
remnants.  He  fully  recovered;  but  how  many  deaths  did 
he  cause — going  from  railroad  car  to  railroad  car,  from 
stagecoach  to  stagecoach,  from  hotel  to  hotel?  How  many 
may  have  been  the  physicians   who   searched  in   vain   for 

134 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

the  cause  of  the  sporadic  cases  suddenly  springing  up  in 
their  towns,  and  the  epidemics  generated  by  them  along 
the  roads  on  which  the  luckless  wanderer  after  his  own 
health  had  strewn  out  his  curses?  Nobody  suspected  the 
traveller  who  left  days  ago,  just  as  nobody  may  be  able 
to  trace  every  outbreak  of  cholera  to  the  unknown  person 
who  carried  it  upon  his  person  or  in  his  bowels.  Nor  is 
this  an  isolated  case  of  a  long  duration  of  diphtheria- 
Cadet  de  Gassicourt  operated  for  laryngeal  diphtheria 
after  eighteen,  twenty-three,  and  forty-three  days.  Sanne 
had  croup  patients  who  recovered  after  twenty-seven, 
thirty-two,  and  sixty  days.  I  know  of  many  cases  of 
diphtheria  protracted  into  the  second  or  even  the  third 
month. 

Golay  reported  the  case  of  a  boy  of  five  years  who  had 
the  diphtheria  bacillus  three  hundred  and  sixty-two  days. 

During  this  time  he  had  three  acute  attacks  of  diph- 
theria and  four  injections  of  antitoxin.  Golay  draws  the 
conclusions  from  his  report  {Revue  medicale  de  la  Suisse 
Romande,  1897)  that  a  fortnight's  isolation  after  the  dis- 
appearance of  the  false  membrane,  as  advised,  is  inade- 
quate; he  does  not  believe  in  recovery  until  three  or  four 
examinations  for  bacilli  made  in  intervals  of  a  week  each 
have  proved  unsuccessful.  He  also  finds  that  the  presence 
of  the  bacillus  in  the  throat  does  not  interfere  per  se 
with  the  general  health;  also  that  the  bacillus  is  apt  to 
remain  a  very  long  time  unless  there  is  a  complicating 
streptococcus  infection.  In  this  case  he  tried  many  local 
applications   (Loeffler's  included)   in  vain. 

Such  facts,  pointing  as  they  do  to  the  ready  communi- 
cability  of  diphtheria,  have  influenced  my  opinion  from 
early  times.  I  cannot  see  anything  miraculous  in  the  sud- 
den appearance  of  a  bacillus  diphtherice  or  a  streptococcus 
in  a  person  apparently  not  exposed  to  it.  During  an 
epidemic  there  is  nobody  not  exposed  to  it,  and  everybody  is 
subject  to  it  under  favorable  circumstances.  The  latter 
mean  a  fit  condition  of  the  human  integument,  either  cutis 
or  mucous  membrane,  which  makes  it  liable  to  become  a 
resting-place  for  the  germ.  That  fit  condition  is  a  slight 
or  severe  wound,  abrasion,  denudation  of  the  surface.     As 

135 


DR.    JACOBFS    WORKS 

no  healthy  surface  becomes  erysipelatous  in  spite  of  ery- 
sipelas being  epidemic  ("  erysipela  non  est  sine  vulnere," 
Galen),  as  Fehleisen's  bacillus  requires  a  sore,  so  diph- 
theria, being  ubiquitous  and  waiting  for  a  chance,  will 
stick  to  a  cutaneous  wound,  a  stomatitis,  a  pharyngeal  or 
nasal  catarrh,  and  will  rapidly  multiply.  A  resected  ton- 
sil will  thus  be  covered  with  a  pseudomembrane  within  a 
day. 

I  have  been  quoted  as  favoring  the  sewer-gas  origin  of 
diphtheria,  though  (with  the  exception  of  a  careless  ex- 
pression on  page  50  of  my  "  Treatise  on  Diphtheria  ") 
I  always,  since  I860,  strenuously  expressed  my  con- 
viction of  the  communicability  of  diphtheria  solely  by  con- 
tagion (direct  or  indirect).  Jenner  in  1861,  Wilks  in 
1873,  Thorne  Thome  in  1893,  expressed  the  same  opinion. 
I  believe  it  is  the  latter  careful  and  most  painstaking  ob- 
server whose  statements,  together  with  the  discussion  on 
the  subject  contained  in  the  British  Medical  Journal  of 
1893  and  1894,  in  which  Wilks,  Davis,  Priestley,  C.  M. 
Jessop,  and  J.  Bunting — in  opposition  to  George  Johnson, 
Parker,  C.  N.  Allfrey,  N.  G.  Warrey,  and  P.  G.  Mar- 
riott— favored  the  exclusive  contagion  theory,  have  done 
most  to  establish  the  latter  forever  in  the  minds  of  our 
British  brethren. 

The  vitality  of  bacilli  is  remarkable.  It  is  true  that 
direct  light  kills  them  after  a  while;  even  diffuse  light 
has  a  similar  though  slower  effect.  It  is  also  true  that 
they  do  not  live  outside  the  body  so  long  as  on  the  hu- 
man mucous  membrane,  and  that  one  observer  (Spengler) 
did  not  find  them  after  one  hundred  and  twenty  days,  and 
others  (Wright  and  Emerson)  found  few  only  on  brushes, 
and  none  on  clothing  or  on  the  finger  nails.  But  Abel 
found  them  on  children's  building  blocks  after  five  months. 
They  resist  desiccation  a  long  time,  in  membranes  (Roux 
and  Yersin,  Park,  Loeffler,  Germano),  in  tissues  (Loeffler, 
d'Epine  et  de  Marignac),  and  in  dust  (Reyes,  Germano). 
Rapid  desiccation,  even  by  means  of  sulphuric  acid,  does 
not  injure  their  virulence,  which  is  preserved  the  better 
(being  protected  against  oxidation)  the  thicker  the  sur- 
rounding dust.     The  latter  may  be  the  vehicle  of  conta- 

136 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

gion.  Moreover,  weeks  and  months  after  an  attack  of 
diphtheria,  bacilli  have  been  and  are  constantly  met  with 
in  the  throat,  nose,  antrum,  and  middle  ear.  We  should 
not  forget  that  no  number  of  negative  observations  can 
outweigh  a  single  positive  result.  And  we  do  know,  those 
of  us  who  have  not  forgotten  the  value  of  clinical  ob- 
servation, that  the  infection  of  diphtheria  in  bedding  and 
in  rooms,  which  harbored  diphtheria  a  year  previously, 
has  started  it  again  in  newcomers  after  they  had  dwelt 
there  long  enough  for  incubation. 

There  is  no  origin  for  diphtheria  except  in  contagion. 
Sewerage  has  nothing  to  do  with  it.  In  a  paper  published 
in  the  Transactions  of  the  Third  Congress  of  American 
Physicians  and  Surgeons  (1894)  I  presented  the  follow- 
ing conclusions: 

The  atmosphere  contains  more  or  less  specific  disease 
germs,  both  living  and  dead. 

They  are  frequently  found  in  places  which  were  in- 
fected with  specific  disease. 

In  sewer  air  fewer  such  germs  have  been  found  than 
in  the  air  of  houses  and  schoolrooms. 

Moist  surfaces — that  is,  the  contents  of  cesspools  and 
sewers  and  the  walls  of  sewers — while  emitting  odors  do 
not  give  off  specific  germs,  even  in  a  moderate  current 
of  wind. 

Splashing  of  the  sewer  contents  may  separate  'some 
germs  and  then  the  air  of  the  sewer  may  become  tem- 
porarily infected,  but  the  germ  will  sink  to  the  ground 
again. 

Choking  of  the  sewer,  introduction  of  hot  factory  refuse, 
leaky  house  drains,  and  absence  of  traps  may  be  the 
causes  of  sewer  air  ascending  or  being  forced  back  into 
the  houses.  But  the  occurrence  of  this  cornplication  of 
circumstances  is  certain  to  be  rare. 

Whatever  rises  from  the  sewer  under  these  circumstances 
is  offensive  and  irritating.  A  number  of  ailments,  in- 
clusive perhaps  of  sore  throats,  may  originate  from  these 
causes.  But  no  specific  diseases  will  be  generated  by  them 
except  in  the  rarest  of  conditions.  For  specific  germs  are 
destroyed   by   the   process   of   putrefaction   in   the   sewers, 

137 


DR.    JACOBI'S    WORKS 

and  the  worse  the  odor  the  less  is  the  danger,  particularly 
from  diphtheria. 

The  contributing  causes  of  the  latter  disease  are  very 
numerous,  and  the  search  for  the  origin  of  an  individual 
case  is  often  unsuccessful. 

Irritation  of  the  throat  and  nasopharynx  is  a  frequent 
source  of  local  catarrh;  this  creates  a  resting-place  for 
diphtheria  germs,  which  are  ubiquitous  during  an  epidemic, 
and  thus  an  opportunity  for  diphtheria  is  furnished. 

Of  the  specific  germs,  those  of  typhoid  fever  and 
dysentery  appear  to  be  the  least  subject  to  destruction 
in  cesspools  and  sewers.  These  diseases  appear  to  be 
sometimes  referable  to  direct  exhalation  from  privies  and 
cesspools,  but  very  few  cases,  if  any,  are  attributable 
to  the  action  of  sewer  air. 

The  impossibility  or  great  improbability  of  the  infection 
of  specific  diseases,  except  dysentery  and  tj'phoid  fever, 
rising  from  sewers  into  our  houses,  protected  as  they  are, 
or  ought  to  be,  by  good  drains  and  efficient  traps,  should, 
however,  not  lull  our  citizens  and  authorities  into  indolence 
and  carelessness.  For  the  general  health  suffers  from 
chemical  exhalations,  and  the  vitality  of  cell  life  and  the 
power  of  resistance  are  undermined  by  them. 

SYMPTOMATOLOGY 

Prodromes. — After  an  incubation  period  lasting  from 
a  few  hours  to  fourteen  days,  prodromes  may  precede  the 
characteristic  symptoms  of  diphtheria  from  a  few  hours 
to  several  days;  some  of  them  are  identical  with  those  of 
general  malaise,  and  nausea;  occasionally  vomiting,  seldom 
other  infectious  diseases.  They  are  lassitude,  headache, 
diarrhoea,  more  commonly  constipation ;  universal  muscu- 
lar sensitiveness,  and  some  stiffness  of  the  neck.  The 
throat  is  complained  of  by  older  children  as  being  dry; 
the  mouth  is  easily  opened,  there  may  be  no  discoloration 
of  the  fauces,  or  a  hyperaemia  only  which,  as  if  it  were 
traumatic,  may  be  quite  local.  The  tonsils  and  pharynx 
are  seldom  sensitive  to  the  touch,  but  the  swallowing  of 
fluids  is  rather  difficult.     In  those  cases  in  which  a  swelling 

138 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

of  lymph  bodies  is  noticed  near  the  angle  of  the  lower 
jaw  at  this  early  period,  there  is  pain  on  pressure.  The 
temperature  is  seldom  raised  except  in  these  cases ;  in 
them  nervous  symptoms  are  observed,  such  as  chills  and 
convulsions.  There  is  rarely  a  short  pharyngeal  cough, 
still  less  frequently  a  hoarse  voice,  or  dyspnoea,  or  laryn- 
geal stridor. 

SYMPTOMS 

The  Throat. — Most  cases  of  diphtheria  begin  in  the 
throat.  The  tonsils  being  large  in  the  young,  and  ex- 
posed to  superficial  lesions  occasioned  by  catarrhal  proc- 
esses, and  to  injuries  of  the  epithelium  (during  degluti- 
tion), are  most  readily  invaded  by  bacilli  and  other  mi- 
crobes. There  may  be  no,  or  a  slight,  or  a  high  elevation 
of  temperature.  This  difference,  like  all  other  symptoms, 
depends  on  the  various  degrees  of  virulence  of  the  in- 
vading micro-organisms,  on  the  previous  immunity,  and 
on  the  different  powers  of  resistance  on  the  part  of  the 
patients.  When  the  temperature  is  high  (104°-107°)  there 
may  be  a  convulsion,  or  vomiting,  or  sometimes  diarrhoea. 
But  these  symptoms  of  the  initial  stage  are  rare. 

The  throat  is  red,  all  over  in  most  cases,  or  locally; 
mostly  on  the  tonsil,  or  near  it,  there  is  a  grayish  or 
whitish  spot,  the  size  of  the  head  of  a  pin,  or  larger. 
Sometimes  the  first  inspection  reveals  the  presence  of  a 
membrane  of  the  same  color  or  brownish.  The  small 
grayish  spot  will  increase  within  a  few  hours  or  a  day 
until  it  grows  into  a  membrane,  or  there  are  more  than 
one,  four  or  six  or  more,  which  soon  coalesce.  The  mem- 
brane may  be  thin  like  a  film,  or  thick;  lying  rather  loose 
on  the  mucous  membrane,  or  tightly  adhering  so  that  its 
removal  is  difficult  and  attended  with  a  little  bleeding; 
when  it  is  removed  it  is  reproduced  in  a  few  hours  or 
half  a  day.  The  grayish  discoloration  is  not  always  mem- 
branous; quite  frequently  it  is  caused  by  an  exudation 
into  the  tissue  and  cannot  be  removed  at  all.  Then  it 
does  not  come  away  at  any  time  but  undergoes  a  process 
of  necrosis,  and  if  it  heals  at  all  does  so  only  by  healthy 
granulations  springing  up  on  the  ulcerating  surface.    The 

139 


DR.    JACOBrS   WORKS 

neighboring  tissues,  mainly  the  uvula  when  it  is  covered 
with  membrane,  become  oedematous  and  may  swell  con- 
siderably. Then  deglutition,  respiration,  and  articulation 
may  suffer  accordingly.  At  first  the  membrane  has  no 
odor.  In  bad  cases,  and  after  some  days,  when  maceration 
begins,  there  is  some  odor,  which  may  be  very  offensive 
and  fetid  in  septic  cases.  In  the  neighborhood  of  the 
membranes  the  lymph  bodies  will  swell,  the  region  of  the 
tonsils  becomes  painful  on  pressure,  and  there  is  some,  or 
much,  swelling,  which  depends  in  part  on  the  tumefaction 
of  the  lymph  bodies  alone,  and  in  part  on  that  of  the 
surrounding  loose  tissue.  The  face  is  pale  and  sallow, 
may  be  bloated  even  in  mild  cases,  and  its  expression  is 
liable  to  be  that  of  indolence  and  apathy;  in  bad  cases  of 
sepsis  and  when  the  veins  of  the  neck  are  compressed  by 
exudation  the  color  may  become  livid.  There  are  but  few 
mild  cases  of  uncomplicated  diphtheria  that  do  not  exhibit 
some  constitutional  symptoms;  the  pulse  becomes  a  little 
frequent  and  small;  in  bad  cases  it  is  very  small,  very 
frequent,  or  very  slow.  Those  cases  in  which  the  pharyn- 
geal diphtheria  spreads  into  nasopharynx,  nares,  or  larynx 
have  their  own  additional  symptoms ;  they  will  be  consid- 
ered below,  so  will  be  those  which  terminate  in  destruction 
of  tissue  in  the  throat  in  consequence  of  deep  ulceration 
and  gangrene,  which  may  even  result  (though  that  oc- 
currence be  rare)  in  perforation  of  the  soft  palate,  or 
its  adhesion  to  the  posterior  wall  of  the  fauces. 

The  local  symptoms  of  diphtheria  may  be  very  indis- 
tinct, even  absent.  As  early  as  I860  I  described  cases 
of  diphtheria  without  membrane,  this  being  absent  either 
in  the  first  stage  only  or  altogether.  At  the  present  time 
the  bacteriological  proof  corroborates  what  I  then  had 
ample  reasons  to  conclude  from  clinical  facts.  The  term 
catarrhal  diphtheria  has  been  accepted  by  many  since, 
though  it  has  been  combated  by  others.  That  such  cases  may 
occur  in  families  in  other  members  of  which  well-autlienti- 
cated  instances  of  diphtheritic  membranes  are  met  with  has 
been  substantiated  by  many,  among  whom  I  am  glad  to 
count  Baginsky.  To  call  such  cases  "  masked  diphtheria  " 
appears   unjustifiable,    so   long   as   the   diagnosis   is   made, 

140 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

as  now,  by  the  presence  of  the  bacillus  and  of  acute  sur- 
face  changes   in   the  mucous   membrane. 

Diphtheria  may,  and  frequently  does,  present  itself,  with 
its  solitary  dots  on  the  tonsils,  in  the  form  of  follicular  or 
lacunar  angina.  Long  before  the  advent  of  a  bacteriologi- 
cal diagnosis  that  fact  became  clear  to  me.  Still  the  nu- 
merical percentages  of  such  cases  will  change  even  accord- 
ing to  seasons  and  epidemics.^ 

This  follicular  form  of  diphtheria  is  often  noticed  in 
adults,  and  is  a  frequent  cause  of  communication  of  the 
disease,  the  more  easily  as  adults  are  less  liable  to  suffer 
from  constitutional  symptoms.  But  I  never  said  what  I 
have  been  charged  with,  that  diphtheria  is  spread  by 
adults  suffering  from  follicular  amygdalitis  (tonsillitis). 
On  the  contrary,  what  I  did  and  do  say  is  that  what  was 
called  in  an  individual  case  by  that  name  and  then  gave 
rise  to  diphtheria,  was  diphtheria,  and  therefore  caused 
diphtheria.  Nor  do  I  say  that  every  case  of  follicular 
affection  of  the  tonsils  is  diphtheria,  and  that  diphtheria 
in  general  is  spread  by  follicular  amygdalitis  in  general, 
but  I  claim  that  this  name  is  too  often  only  a  cloak  for 
the  lack  of  a  correct  or  complete  diagnosis.  "  Follicular  " 
and  "  lacunar  "  are  adjectives  describing  a  locality,  noth- 
ing else.  There  are  cases  of  a  follicular  or  lacunar  amyg- 
dalitis of  a  catarrhal,  a  purulent,  a  fibrinous,  and  a  diph- 
theritic character,  and  the  name  ought  to  be  dropped  from 
our  nomenclature,  because  it  gives  rise  to  mistakes  unless 
it  be  complemented  with  a  descriptive  adjective  (Medical 
Record,  November  27,   1886).      This  variegated  condition 

2  If  Edmund  Meyer's  55  cases  of  "typical"  angina  lacunaris 
gave  him  staphylococcus  aureus  in  15,  a  mixture  of  staphylococcus 
and  streptococcus  in  24,  streptococcus  pyogenes  in  14,  and  Klebs- 
Loeffler  bacillus  in  only  2  instances,  he  had  an  experience  dif- 
ferent from  those  of  Lennox  Browne,  Koplik,  and  Feer  ("  Aetio- 
logische  und  klinische  Beitrage  zu  Diphtheric,'  1894,  p.  43).  The 
latter  should  hold  himself  responsible  for  the  following  words 
literally  translated:  "It  is  an  established  fact  that  many  cases 
of  lacunar  anginae  are  of  diphtheria  origina,  though  Jacobi's  opin- 
ion, according  to  which  that  is  so,  has  become  untenable  through 
bacteriological  research." 

141 


DR.    JACOBI'S    WORKS 

of  the  tonsils  and  pharynx  was  also  described  by  me  in 
an  article  "  On  Diphtheria  and  Diphtheritic  Affections," 
in  the  American  Medical  Times,  August  11  th  and  18th, 
I860,  and  in  C.  Gerhardt's  "  Handbuch  der  Kinderkrank- 
heiten,"  II.,  1877. 

The  follicular  form  of  amygdalitis  (diphtheritic  or 
other),  causing  local  and  small  circumscribed  alterations 
only,  may  easily  be  mistaken  for  a  similar  circumscribed 
deposit  which  is  not  in  a  tonsillar  lacuna,  but  on  some 
other  part  of  the  tonsil.  This  punctuated  diphtheria  is 
mostly  seen  in  larger  children,  in  adolescents,  and  in  adults, 
for  the  reason  that  renewed  attacks  of  pharyngeal  inflam- 
mation so  harden  and  cicatrize  the  tonsillar  surface  that 
extensive  exudations  can  no  longer  take  place.  The  broad 
statement  is  justified  that  pharyngitis  creates  a  disposition 
to  diphtheria  and  to  the  formation  of  large  membranes  in 
the  very  young,  and  rather  destroys  it  or  causes  only  small 
exudations  in  advanced  age.  But  whether  membrane  or 
dot,  they  are  equally  contagious.  A  mild  variety  begets 
that  which  is  mild  or  severe,  as  the  severe  form  may 
produce  its  like,  or  a  mild  variety.  This  mild  variety  is 
that  from  which  adults  are  apt  to  suffer.  It  made  me 
proclaim  the  warning  that  there  is  as  much  diphtheria 
out  of  doors  as  indoors,  as  much  out  of  bed  as  in  bed. 
With  this  variety  the  adult  is  on  the  street,  engaged  in 
business,  in  the  schoolroom,  in  the  railroad  car,  in  the 
kitchen,  and  in  the  nursery.  With  this  variety  parents, 
while  complaining  of  slight  throat  trouble,  which  is  not 
heeded,  kiss  their  children  and  infect  them  (Medical 
Record,  November  27th,  1886). 

The  confusion  in  regard  to  the  accurate  diagnosis  of 
an  individual  case  is  caused  by  the  difficulty  of  alwaj's  es- 
tablishing the  temporary  presence  or  absence  of  the  Klebs- 
Loeffler  bacillus.  Having  noticed  the  frequent  identity  of 
lacunar  "  tonsillitis  "  with  diphtheria,  C.  Fraenkel,  E. 
Czaplewski,  and  others  "  believe  "  that  bacilli  are  actually 
more  common  than  is  generally  assumed,  and  that  numer- 
ous alleged  cases  of  streptococcus  pseudodiphtheria  are, 
after  all,  caused  by  the  bacillus,  and  that,  on  the  other 
hand,  uncomplicated  bacillary  diphtheria  is  quite  rare. 

142 


DIPHTHERIA:  SYMPTOMS  AND  TREATMENT 

Another  cause  of  confusion  was  the  assumption  that  gen- 
uine bacillary  diphtheria  was  the  most  dangerous  form 
of  the  disease.  There  was  a  time  when  the  diagnosis  of 
diphtheria  was  made  by  the  omniscients  from  the  ter- 
mination of  the  case:  if  the  patient  died,  it  was  diphtheria; 
if  not,  not.  The  advent  of  the  bacillus  has  changed  that; 
the  bacillus  case  is  at  once  made  out  to  be  the  most  dan- 
gerous and  fatal  case.  Nothing  is  more  erroneous.  As 
a  rule  the  uncomplicated  bacillus  case  is  not  among  the 
fatal  cases ;  as  a  rule  the  uncomplicated  streptococcus  case 
is  not  fatal;  but  the  mixed  case  is  ominous.  The  elimina- 
tion or  non-appearance  of  one  of  these  components  is  a 
favorable  occurrence.  The  latest  illustration  of  this  fact 
is  the  report  of  Strassburger,  who  states  that  the  large 
majority  of  diphtheria  sufferers  in  Bonn  carried  Klebs- 
Loeffler  bacilli  which  were  comparatively  harmless.  These 
mild  cases  were  not  complicated  with  streptococci,  which 
were  present  in  every  grave  case. 

Skin. — An  erythematous  eruption,  more  or  less  general, 
appears  sometimes  on  the  skin  immediately  with  the  in- 
vasion of  diphtheria,  or  after  a  few  days  only.  It  is  either 
evanescent,  scarcely  visible  for  more  than  a  few  hours,  or 
covers  a  large  surface  and  remains  some  days.  It  has  been 
mistaken  for  scarlet  fever,  but  is  not  generally  attended 
with  a  high  temperature  and  with  the  intense  stomatitis 
and  glossitis  of  scarlatina;  by  the  lower  temperature  it 
is  also  distinguished  from  the  erythema  which  is  liable  in 
predisposed  infants  or  children  to  accompany  many  fever- 
ish diseases. 

This  eruption  of  diphtheria  does  not  appear  to  be  pro- 
portionate to  the  seriousness  of  the  illness.  At  all  events 
it  has  nothing  in  common  with  erysipelas,  which,  however, 
is  apt  to  accompany  such  cutaneous  diphtheria  as  follows 
abrasions  of  the  skin,  and  is  found  on  tracheotomy  or 
other  wounds.  Such  local  deposits  of  diphtheritic  mem- 
branes are  often  found  on  the  local  denudations  of  scratch 
wounds,  eczema  sores,  or  vesicatories.  They  are  apt  to 
remain  local ;  but,  on  the  other  hand,  in  many  cases  in 
which  the  first  localization  of  diphtheria  is  in  the  skin, 
it   will    affect   the    neighboring    lymph    bodies    and    infect 

143 


DR.    JACOBI'S    WORKS 

the  whole  body.  As  a  rule,  however,  it  is  amenable  to  early 
and  effective  treatment,  and  that  is  why  Trousseati  de- 
clared most  cases  of  cutaneous  diphtheria  to  be  devoid  of 
danger. 

In  connection  with  these  cutaneous  alterations  may  be 
mentioned  the  more  or  less  local  or  general  emphysema 
which  occurs  sometimes  during  or  after  tracheotomy.  I 
had  that  disagreeable  experience  a  number  of  times,  on  ac- 
count of  my  preferring  to  operate  mostly  below  the  thy- 
roid gland.  There  the  mediastinal  tissue  is  sometimes  in- 
jured, and  during  the  intense  dyspnoea  a  local  emphysema 
of  the  subcutaneous  tissue  is  the  instantaneous  result.  Even 
from  a  slight  rupture  of  pulmonary  alveoli  much  air  will 
escape  and  the  whole  body  may  become  transformed,  as  it 
were,  into  a  bulging,  crepitating  balloon. 

Extensive  oedema  is  sometimes  noticed,  even  without  al- 
buminuria. 

In  connection  with  the  alterations  of  the  skin  petechiae, 
purpura,  and  ecchymoses  may  be  mentioned,  though,  in- 
deed, they  might  find  their  proper  place  also  under  the 
head  of  the  organs  of  circulation.  Like  scarlatina  and, 
still  more,  measles,  and,  indeed,  all  infectious  diseases, 
diphtheria  (principally  the  mixed  bacillus  and  streptococ- 
cus infection),  mainly  when  the  myocardium  is  altered  and 
when  blood-vessels  are  obstructed,  will  result  in  effusion 
and  either  small  or  large  extravasations.  Beside  the  lat- 
ter in  its  different  forms  urticaria,  erysipelas,  and  variola- 
like eruptions  will  be  observed.  There  is,  however,  no 
eruption  that  is  pathognomonic  of  genuine  diphtheria. 

The  local  lesion  of  the  mucous  membranes  gives  rise 
to  bloody  discharges  from  the  nares  or  the  pharynx. 
When  sepsis  is  very  intense  and  gangrene  deeper,  actual 
hemorrhage  will  occur.  The  large  majority  of  dangerous 
or  fatal  hemorrhages  come  from  tracheotomy  wounds,  now 
and  then,  perhaps,  from  mere  pulmonary  hyperaemia  and 
apoplexy,  sometimes  after  the  loosening  of  membranes,  or 
from  erosion  of  larger  blood-vessels.  Now  and  then  the 
pressure  of  an  improper  tracheotomy  tube  would  cause  it, 
ns  in  Ganghofner's  and  in  Maas's  cases  of  hemorrhage 
from  the  innominata,  sometimes  the  septic   destruction  of 

144 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

a  carotid  artery,  as  in  a  case  described  by  me  (Transac- 
tions of  the  Association  of  American  Physicians,  1898), 
or  that  of  other  large  blood-vessels  would  lead  to  a  fatal 
termination   from  profuse  bleeding. 

Nose. — The  diphtheritic  membranes  spread  quite  often 
from  the  throat  to  the  nasal  cavities,  mainly  when  the 
posterior  aspect  of  the  uvula  is  affected.  The  latter's  fre- 
quent contact  with  the  posterior  wall  of  the  pharynx  dur- 
ing deglutition  exposes  the  posterior  wall  of  the  pharynx 
as  well.  In  many  such  cases  the  membrane  is  very  thick 
and  dense,  and  apt  to  obstruct  the  nasal  passages  some- 
times to  such  an  extent  as  to  close  them  entirely.  Usually 
there  is  no  or  very  little  nasal  discharge ;  but  articulation 
becomes  "  nasal  "  and  the  voice  "  thick  "  very  soon,  and 
respiration  is  hampered.  The  deep  facial  lymph  bodies 
near  the  angle  of  the  lower  jaw  are  more  or  less  swollen. 
Whenever  they  are  so,  the  nasopharynx  should  be  examined. 

Primary  diphtheria  of  the  nose  (diphtheric  or  diph- 
theritic rhinitis)  is  of  frequent  occurrence.  Either  with- 
out any  prodromi,  or  during  or  after  an  acute  or  a  chronic 
nasal  catarrh,  with  much  or  with  little  discharge,  there  is 
a  thin,  serous,  or  slightly  flocculent  secretion  which  is  more 
or  less  profuse,  sometimes  not,  sometimes  slightly,  other 
times  intensely  fetid.  Hence,  during  the  prevalence  of  a 
diphtheria  epidemic,  every  nasal  (or  pharyngeal)  catarrh 
requires  immediate  attention.  This  primary  form  may  also 
lead  to  the  exudation  of  thick  membranes,  as  described 
above;  the  general  consecutive  symptoms  so  much  to  be 
dreaded  do  not  depend,  however,  on  the  thickness  of  the 
membranes.  On  the  contrary,  in  many  cases  with  only 
thin  membranous  deposits  the  lymph  bodies  are  more  af- 
fected, and  the  effect  of  the  toxin  becomes  painfully  vis- 
ible in  the  either  very  slow  or  rapid  and  feeble  pulse  with 
all  the  other  symptoms  of  a  generalized  sepsis.  The  cervical 
adenitis  has  but  little  tendency  to  suppuration;  but  a  gan- 
grenous degeneration  takes  place  mainly  in  the  mixed  in- 
fections, or  chronic  hyperplastic  infiltrations  tell  their 
tales  for  years  to  come.  There  is  no  more  dangerous 
form  of  diphtheria  than  that  of  the  nares.  Still  more, 
however,    than   the    foul-smelling    cases    are   to    be    feared 

145 


DR.    JACOBI'S    WORKS 

those  which  exhibit  few  membranes,  but  at  an  early  period 
a  sanguinolent  discharge.  In  these  not  even  the  lymph 
bodies  may  swell,  but  absorption  will  take  place  directly 
through  the  blood-vessels,  which  are  open,  as  is  proved 
by  the  very  presence  of  blood  in  the  discharges. 

So  long  as  the  final  clinical  diagnosis  of  diphtheria  de- 
pends on  the  presence  of  the  bacillus,  if  found,  in  the 
membrane  or  in  the  discharge,  the  numberless  papers 
strutting  about  the  magazines  to  prove  either  the  innocu- 
ousness  or  the  dangerousness  of  fibrinous  rhinitis,  or  again 
the  presence  or  absence  of  bacilli  in  fibrinous  rhinitis,  or 
its  ability  or  inability  to  cause  faucial  or  laryngeal  diph- 
theria, are  superfluous  vaporings  of  single  observations. 
Whenever  nasal  diphtheria  is  diagnosed  in  any  of  its 
forms,  or  even  strongly  suspected,  danger  should  be  as- 
sumed to  exist.  In  most  cases  the  infection  is  mixed,  very 
mixed.  Edmund  Meyer  (Archiv  fiir  Larytigologie  und 
Rhinologie,  IV.,  1896)  found  in  twenty-two  cases  of  "fi- 
brinous rhinitis,"  nine  times  streptococci  and  staphylococci 
albi  and  aurei,  and  thirteen  times  Klebs-Loeffler  bacilli; 
Guarnaccia,  in  his  cases  of  "  caseous  rhinitis,"  found  Klebs- 
Loeffler  bacilli,  streptococci,  staphylococci  aurei  and  albi, 
sarcina  lutea,  bacillus  subtilis,  bacillus  proteus,  leucocytes 
containing  microbes  in  their  nuclear  protoplasm,  and 
streptothrix  alba. 

The  conjunctiva  of  the  upper  (more  frequently)  or  the 
lower  eyelid  becomes  diphtheritic  either  primarily  or  sec- 
ondarily (when  the  nose  and  lacrymal  ducts  are  primarily 
affected).  Diphtheritic  conjunctivitis  is  not  a  frequent 
disease — sometimes  I  do  not  see  a  case  in  a  year;  thirty- 
five  years  ago  it  was  frequent  and  destructive.  Evidently 
the  epidemics  differ  in  regard  to  virulence.  Usually  the 
membrane  spreads  rapidly  from  one  eyelid  to  the  other; 
when  the  palpebral  conjunctiva  is  smooth,  dry,  and  pale, 
while  that  of  the  bulbus  is  chemosed,  the  whole  lid  becomes 
red,  swells  and  stiffens,  and  a  membrane  is  first  deposited 
in  floccules,  which  soon  coalesce  into  solid  masses.  These 
are  so  thick  as  to  press  upon  the  cornea,  which  speedily 
becomes  hazy  and  ulcerates.  Perforation  takes  place,  the 
iris  prolapses,  and  sometimes  the  eye  is  destroyed  within 

146 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

a  single  day.  It  takes  the  membrane  a  few  days  to  begin 
maceration. 

The  accurate  diagnosis  of  the  character  of  the  mem- 
brane should  be  made  in  the  usual  way;  in  many  cases 
simple  film  preparations,  to  the  exclusion  of  cultivation, 
are  sufficient.  It  is  claimed  by  Moray  (Annates  d'oculis- 
tique,  April,  1895)  and  Sydney  Stevenson  (British  Medi- 
cal Journal,  June  18th,  1898)  that  quite  often  the  dis- 
charge from  the  eye  contains  only  that  microbe  which  is 
the  cause  of  the  inflammation.  There  is  only  one  source 
of  confusion  likely  to  arise,  viz.,  that  between  Klebs- 
Loeffler   and   xerosis   bacilli.^ 

According  to  Ammann*  the  cornea  may  be  affected  by 
the  Klebs-Loeffler  bacillus,  alone,  but  is  mostly  invaded 
only  when  strepto-  and  staphylococci  are  present.  Once 
he  found  non-virulent  bacilli  together  with  the  virulent. 

The  ear  is  liable  to  take  part  in  the  diphtheria  of  the 
nasopharynx.  Membranes  may  continue  into  the  funnel- 
like aperture  of  the  Eustachian  tube,  which  in  the  j^oung 
is  relatively  larger  than  in  the  adult,  or  the  specific  ca- 
tarrh   (a   mere   surface   diphtheria)    may   extend   into    the 

3  The  main  points  of  distinction  are  (according  to  Stevenson) : 
1.  Both  stain  by  Gram's  method,  but  tlie  diphtheria  organism 
loses  its  gentian  violet,  when  in  alcohol,  much  more  quickly  than 
the  xerosis  bacillus.  2.  Klebs-I>oeffler  bacilli  give  rise  to  an  acid 
reaction  when  grown  in  neutral  bouillon  or  milk,  while  xerosis 
bacilli  never  do.  3.  The  latter,  when  inoculated  into  guinea-pigs, 
cause  nothing  more  than  a  swelling  at  the  site  of  the  puncture. 

*  The  xerosis  bacillus  is  believed  by  Schanz  to  be  identical  with 
the  Klebs-Loeffler.  Its  microscopical  features  vary,  but  not  more 
so  than  those  of  the  latter  and  of  the  "  pseudobacillus."  It  dif- 
fers in  this  also  that,  tliough  it  is  always  combined  with  strep- 
tococci, it  is  not  believed  to  be  virulent,  inasmuch  as  it  does  not 
cause  diphtheria.  Still,  there  is  a  case  of  von  Hippel — examined 
by  C.  Fraenkel  also — which  proved  the  virulence  of  the  xerosis 
bacillus.  It  was  met  with  in  the  conjunctival  sac  of  a  man  who 
had  been  operated  iqjon  for  cataract.  It  was  found  to  be  very 
vindent  in  animal  experimentation,  thovigh  on  the  eye  of  the 
patient  there  was  no  kind  of  inflammation,  least  of  all  diphtheria. 
The  absence  of  diphtheria,  however,  in  the  presence  of  Klebs- 
Loeffler  bacillus  on  mucous  membranes  is  a  frequent  occurrence. 

147 


DR.    JACOBFS    WORKS 

middle  ear.  Since  I  collected  what  little  literature  there 
was  in  1880  ("  Treatise,"  p.  75),  instances  of  that  kind 
have  multiplied.  The  drum  membrane,  the  external  meatus, 
and  the  lobes  are  subject  to  diphtheria  when  the  surface 
epithelium  has  been  injured.  A  complication  with  erysipe- 
las I  saw  thirty  years  ago  on  the  external  ear  of  a  newly- 
born  child ;  in  older  children  I  have  seen  that  same  un- 
fortunate complication  during  bad  epidemics ;  also,  with- 
out erysipelas,  a  gangrenous  disintegration  of  the  cheek, 
of  the  external  ear,  sometimes  down  into  the  bones,  with 
all  the  possibilities  arising  in  the  various  forms  of  otitis 
media  and  osteitis.  While  some  died  of  sepsis,  others  would 
succumb  to  thrombotic  obstructions  of  a  sinus. 

The  kidneys  are  liable  to  participate  in  most  infectious 
diseases,  even  in  the  common  forms  of  pharyngitis ;  in 
none  more  so  than  in  diphtheria,  no  matter  whether  mild 
or  grave.  Evidently  the  irritation  caused  by  the  elimina- 
tion of  the  toxin  damages  either  merely  the  functions  or 
the  substance  of  the  kidneys.  Albuminuria  is  seen  early, 
about  the  third  or  fourth  day^  even  on  the  second,  in  per- 
haps one-third  of  all  the  cases,  while  the  quantity  of  the 
urine  is  rarely  diminished,  sometimes  increased.  Blood 
there  is  very  rarely,  even  in  septic  cases  less  frequently 
than  in  scarlatina.  Urea  is  present  in  normal  or  fair 
quantities,  and  the  salts  are  nearly  normal.  Cylindroids 
(mucin)  and  sometimes  hyaline  casts  are  found  in  these 
simple  cases  in  which  the  albumin  may  be  present  a  few 
days  or  a  week,  without  exerting  an  influence  on  either 
the  temperature  or  the  other  symptoms.  Sometimes, 
after  having  been  quite  copious,  it  disappears  very  sud- 
denly. 

Actual  nephritis  is  not  so  frequent  as  in  scarlatina,  but 
it  occurs.  Hyaline  casts  in  larger  numbers,  turbid  cells, 
small  granular  casts  are  the  first  microscopical  symptoms, 
which  may  be  followed  by  large  granular  casts  and  oc- 
casionally only  a  few  red  blood  cells.  The  urine  becomes 
scanty,  the  skin  more  pallid,  the  collapse  more  intense. 
In  this  nephritis  of  diphtheria  there  is  less  oedema,  less 
dropsy,  less  uraemia  than  in  that  of  scarlatina  or  other 
complications.      Convulsions   are   not   even   so   frequent   in 

148 


DIPHTHERIA:     SYMPTOMS    AND     TREATMENT 

this  stage  as  they  may  be  in  the  incipient  stages  of  such 
cases  as  begin  suddenly  and  with  a  high  temperature.  The 
patients  die,  now  and  then,  without  losing  consciousness 
to  their  last  hour.  A  fatal  termination  is  not  so  common 
as  in  other  complications.  When  albumose  is  found,  to- 
gether with  considerable  albumin,  Berlin  (Munchner  medi- 
cinsche  Wochenschrift,  No.  42,  1897)  believes  the  prog- 
nosis to  be  rather  favorable.  Still  in  most  of  the  cases 
at  the  clinic  of  Strassburg  in  which  he  made  his  obser- 
vations, the  renal  complications  were  only  trifling. 

The  bronchi  and  the  lungs  participate  in  various  ways 
and  at  various  times.  The  pseudomembrane,  whether 
streptococcic  or  bacillary,  descends  into  the  ramifications  of 
the  air  tubes,  or  it  is  first  formed  in  these,  where  it  may 
become  localized  or  whence  it  may  ascend.  This  "  fibrin- 
ous bronchitis  "  may  run  a  rapid  or  a  slow  course.  After 
the  pseudomembranes  have  been  thrown  off,  a  mucopuru- 
lent inflammation  may  remain  and  prove  danger6us  to  the 
exhausted  patient.  Pulmonary  oedema,  with  intense  bron- 
chial hyperaemia  and  extensive  dilatation  of  the  blood-ves- 
sels, results  from  the  rarefaction  of  air  in  the  lungs  during 
laryngeal  obstruction.  This  form  can  be  best  observed 
during  a  tracheotomy  when  it  is  made  after  a  long  dura- 
tion of  stenosis;  an  incredible  amount  of  oedematous  fluid 
will  ascend  from  the  trachea  under  such  circumstances. 
The  intense  bronchitis  accompanying  it  is  frequently  the 
forerunner  of  elevations  of  temperature  and  of  broncho- 
pneumonia within  one  or  two  days.  Broncho-  or  fibrinous 
pneumonia  may  also  follow  the  aspiration  of  membrane 
(as  well  as  of  food)  during  dyspnoea.  The  microbic  na- 
ture of  the  membrane  determines  frequently  the  microscopic 
character  of  the  consecutive  pneumonia,  which  may  be 
simply  pyococcic  but  appears  to  be  mostly  attended  with 
or  caused  by  the  Klebs-Loeffler  bacillus  (Wright,  Kanthack, 
Stephens,  Flexner).  In  the  septic  form,  or  under  ordi- 
nary circumstances  also,  a  gangrenous  pneumonia  has  been 
observed.  Most  pneumonias  observed  in  diphtheria  accom- 
pany, or  are  dependent  on,  the  laryngeal  form  (croup). 
That  is  why  percussion  and  auscultation  do  not  yield  so 
conclusive  results  in  such  cases;  for  dulness  may  be  found 

149 


DR.    JACOBI'S    WORKS 

over  a  merely  atelectatic  area,  and  the  respiratory  murmurs 
are  obscured  by  the  transmitted  sawing,  loud,  laryngeal 
sounds.  Still  when  the  hitherto  low  temperature  is  re- 
placed by  a  high  one,  and  the  normal  long-drawn  inspira- 
tion of  uncomplicated  laryngeal  diphtheria  (croup)  gives 
way  to  great  frequency  of  respiration,  the  suspicion  point- 
ing to  pneumonia  becomes  almost  a  certainty. 

Like  strepto  and  stapln^lococci  the  Klebs-Loeffler  bacillus 
is  found  in  tuberculous  lungs.  It  is  easily  seen  that,  as 
it  is  frequent  on  the  mucous  membranes  of  the  upper  part 
of  the  respiratory  organs,  it  may  readily  appear  in  its 
lower  distributions.  Whetlier  it  modifies  the  tuberculous 
disintegration  remains  an  open  question.  The  influence 
of  the  streptococcus  on  the  tuberculous  process  is  assumed 
by  all  to  be  powerful  for  evil.  While  it  is  possible  and 
appears  to  be  proven  that  the  presence  of  streptococci 
interferes  with  the  growth  of  Klebs-Loeffler  bacilli,  other 
observations  have  shown  that  under  certain  circumstances 
the  non-virulent  bacilli  may  become  virulent  under  the 
influence  or  in  the  presence  of  streptococci  (Schiitz  in 
the  Berliner  klinische    Wochenschrift,  April   18th,    1898). 

The  oesophagus  rarely  participates  in  the  diphtheritic 
affection  of  the  pharynx  beyond  a  distance  of  from  2 
to  3  cm.  where  its  tissue  is  healthy.  If  it  is  not  healthy, 
for  instance  near  cicatricial  contractions,  membranes  may 
be  found  at  any  place.  They  may  be  deposited  loosely 
on  the  mucous  membrane  and  easily  floated,  or  may  be  em- 
bedded in  the  tissue,  and  then  lead   to  necrosis. 

The  stomach  participates  in  the  symptoms  of  incipient 
diphtheria  by  vomiting,  which,  however,  is  not  frequent. 
Gastric  pain  and  vomiting  may  precede  cardiac  parah'^sis. 
Membranes,  however,  are  found  in  exceptional  cases  only. 
In  one  I  concluded  they  were  swallowed  before  death. 
The  intestinal  tract  has  diphtheritic  (dysenteric)  mem- 
branes in  the  rectum  and  colon,  sometimes  in  connection 
with  pharyngeal  (and  nasal)  diphtheria.  Mixed  (bacillus 
and  streptococcus)  infections  are  sometimes  complicated  by 
a  septic  diarrhoea  with  gangrenous  foetor,  and  at  the  same 
time  with  purpura,  nephritis,  and  intestinal  hemorrhages. 
Schwabe   has   reported  the  case  of  a  physician   who  died 

150 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

of  a  septic  diarrhoea  contracted  by  swallowing  membranes 
aspirated  from  a  tracheotomy  wound. 

The  cases  of  diphtheria  of  the  bladder,  vagina,  and 
penis  recorded  by  me  in  my  "  Treatise  "  of  1880,  pp.  86- 
90,  do  not  bear  perhaps  the  present  test  of  bacteriological 
diagnosis.  But  several  cases,  so  verified,  or  diphtheria  of 
the  vagina,  and  of  circumcision  wounds  have  been  seen 
by  me  since.  One  of  the  former  was  met  with  in  a  case 
of  nasopharyngeal  diphtheria,  two  of  them  were  followed 
by  a  faucial  affection,  one  of  these  was  puerperal.  The 
inguinal  lymph  bodies  were  not  much  affected,  but  a  slight 
swelling  I  never  missed.  One  patient  with  diphtheria  of 
a  circumcision  wound,  neglected  and  gangrenous,  died 
with  large  inguinal  adenitis.  Nisot,  Bumm,  and  J.  Whit- 
ridge  Williams  {American  Journal  of  Obstetrics,  August, 
1898)  report  cases  of  diphtheria  of  the  vagina  (and 
uterus).  In  the  case  of  the  latter  the  woman  was  (pos- 
sibly) infected  by  the  physician.  Her  new-born  baby  and 
several  other  children  caught  the  disease  from  her,  and  the 
baby  died. 

There  is  rarely  a  case  of  diphtheria  in  which  the  lymph 
bodies  in  the  neighborhood  of  the  diseased  locality  are 
not  affected.  The  latter  determines  the  swelling  which 
is  to  take  place.  Previous  remarks  explain  why  a  diph- 
theria limited  to  the  tonsils  does  not  cause  much  swelling 
of  the  lymph  bodies,  or  why  that  of  the  vocal  cords  when 
uncomplicated  exhibits  no  secondary  adenitis  at  all,  and 
why  a  nasal  diphtheria  with  sanguinolent  discharge  from 
open  blood-vessels,  though  constituting  a  formidable  va- 
riety of  the  disease  (the  toxin  being  introduced  directly 
into  the  blood  circulation),  should  show  no  tumefied  lymph 
bodies.  These  are  irritated  by  the  absorption  from  the 
diseased  surface,  the  swelling  corresponding  both  to  its 
locality  and  the  gravity  of  the  case.  Bacillary  diphtheria, 
not  or  but  little  complicated  with  streptococci,  shows  less 
adenitis  than  when  the  affection  is  thoroughly  mixed.  Sim- 
ple streptococcic  membranes  yield  more  adenitis  than  a 
mild  bacillary  diphtheria.  That  is  why  so  many  cases  of 
scarlatina  in  which  the  complication  with  streptococci  is 
more   frequent  than   that  with  bacilli,  have   more   faucial 

151 


DR.    JACOBI'S    WORKS 

and  cervical  tumefaction  than  diphtheria.  Suppuration  is 
less  common  in  the  Klebs-Loeffler  affection — Lennox 
Browne's  opinion  notwithstanding — than  in  the  streptococ- 
cic or  in  the  mixed  infection.  Large  abscesses  are  not 
frequent.  Though  the  swellings  be  ever  so  immense  in 
mixed  infections,  they  do  not  abound.  There  may  be 
many  of  them,  but  they  are  mostly  small.  The  degenera- 
tion which  takes  place  is  rather  a  necrosis  and  gangrene 
than  suppuration. 

The  seat  of  the  adenitis  corresponds  with  that  of  the 
diphtheria.  The  posterior  nares  correspond  with  the  deep- 
seated  lymph  bodies  below  and  near  the  angle  of  the  lower 
jaw  to  such  an  extent  that  this  diphtheria,  though  no  mem- 
branes be  visible,  may  thus  be  diagnosticated.  In  very 
grave  cases  the  swelling  will  even  extend  to  the  parotid. 

The  heart  is  probably  affected  in  every  case  of  diph- 
theria. In  Gerhard's  "  Handbuch  der  Kinderkrankheiten," 
Vol.  II.,  1877,  I  mentioned  the  symptoms  with  their  ana- 
tomical foundation  which  I  characterized  as  extravasations, 
cellular  and  nuclear  alterations  (myocardial),  and  endo- 
carditis, first  mentioned  by  Bridges.  Among  17  autopsies 
recorded  by  Reimer  there  was  fatty  degeneration  of  the 
heart  in  6,  and  ecchymosis  of  the  myocardium  in  3  cases. 
In  addition  to  frequent  hyperaemia  of  the  abdominal  vis- 
cera there  were  emboli  of  the  liver  in  3,  with  capillary 
hemorrhages  in  its  peritoneal  covering  in  1,  and  emboli 
in  the  spleen  in  5  cases. 

The  symptoms  do  not  always  correspond  with  the  tangi- 
ble anatomical  changes.  The  results  of  the  thousands  of 
anatomical  and  microscopical  examinations  which  have  been 
made  these  forty  years,  though  they  be  insufficient  to 
explain  the  physical  foundations  of  the  morbid  symptoms, 
do  not  justify  the  establishment  of  a  "  diphtheritic  fever," 
which  I  resorted  to  in  I860  for  the  purpose  of  classify- 
ing just  such  cases  in  which  the  symptoms  did  not  appear 
to  be  based  on  palpable  changes  There  is  no  case  ever 
so  mild  apparently  that  will  not  affect  the  heart's  function 
at  once  to  a  certain  extent.  From  mild  cases  to  the 
gravest  there  are  gradual  transitions  The  skin  is  pale, 
yellowish,  livid,  cyanotic,  sometimes  the  lividity  and  cya- 

152 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

nosis  are  quite  localized,  the  pulse  is  feeble,  mostly  fre- 
quent; in  bad  cases  sometimes  slow,  often  irregular  and 
intermittent;  in  the  worst  cases  filiform  when  near  or  over 
200,  apparently  of  normal  volume  (still  compressible)  when 
quite  slow  (30  to  50),  sometimes  dicrotic,  or  galloping. 
The  heart  is  sometimes  still  more  irregular  than  the  ar- 
terial pulse.  Its  transverse  diameter  is  enlarged,  mainly 
over  the  right  ventricle;  the  sounds  are  muffled  and  drawn 
out,  and  in  this  way  audible  over  a  large  surface.  Real 
bellows  murmurs,  when  localized,  are  met  with  in  endo- 
carditis only.  The  complex  of  symptoms  belonging  to 
actual  parenchymatous  mj'ocarditis  will  generally  not  set 
in  before  the  end  of  the  first  week.  Turbidity  of  cell 
structure,  fatty  or  waxj^  degeneration,  and  loss  of  cross 
striation  are  the  anatomical  changes  which  have  been  veri- 
fied hundreds  of  times ;  they  correspond  to  a  certain  degree 
of  cardiac  incompetency  and  are  probably  due  to  the  in- 
fluence of  the  diphtheria  toxin  only. 

Mollard  and  Regaud  {Annates  de  I'lnstitut  Pasteur, 
1897)  found  affection  of  the  myocardium,  together  with 
changes  in  other  viscera,  in  every  one  of  their  eighteen 
cases  of  experimental  diphtheritic  intoxication.  Occasion- 
ally it  was  confined  to  the  muscular  tissue,  which  became 
abnormally  striated  and  sometimes,  through  disintegration 
of  nuclei  and  protoplasm,  was  destroyed.  Others  report 
the  presence  of  numerous  nuclear  alterations  in  the  car- 
diac muscle  (Kretz),  another  (Hibbard,  Boston  City  Hos- 
pital, 1898)  "in  the  vagus  some  evidence  of  degenerative 
changes." 

The  liver  is  enlarged  and  easier  to  feel  than  the  spleen. 
Its  size  and  resistance  may  increase  tremendously  when 
the  circulation  becomes  sluggish  under  the  influence  of 
general  exhaustion  and  sepsis,  and  of  myocardial  changes. 
Jaundice  is  met  with  in  very  grave  and  septic  cases. 

The  spleen  in  enlarged  in  most  cases,  but  difficult  to 
palpate  because  of  its  softness,  and  to  percuss  because  of 
the  tympanites  which  frequently  attends  the  disease.  Even 
under  normal  circumstances  the  percussion  of  the  spleen 
in  the  very  young  is  not  a  successful  procedure. 

In  Reiner's  cases  the  blood  was  frequently  normal,  very 

153 


DR.    JACOBI'S    WORKS 

often  watery  and  dark,  at  times  leucocytotic ;  the  latter 
condition  was  also  noticed  by  Bouchut  and  Labadie-La- 
grave.  Wunderlich  reported  two  cases  of  Hodgkin's  dis- 
ease which  developed  during  diphtheria;  Bouchut  and  Du- 
brisay  found  leucocytosis  with  considerable  disproportion 
in  the  number  of  red  and  white  cells,  which,  however,  was 
not  great  enough  to  justify  the  diagnosis  of  leucocythaemia. 
Many  examinations  of  the  blood  have  been  made  since, 
all  with  similar  results.  Thus  Gabritchevsky  found  hy- 
perleucocytosis  in  every  case  of  diphtheria.  It  is  greatest 
in  fatal  cases;  during  convalescence  and  after  the  injec- 
tion of  antitoxin  it  diminishes.  A  progressive  hyperleu- 
cocytosis  in  diphtheria  justifies  a  bad  prognosis,  and  the 
analysis  of  the  blood  gives  useful  information  regarding 
the  value  of  treatment.  Ordinarily  the  white  cells  vary  be- 
tween 11,450  and  25,000,  and  in  fatal  cases  between  29,- 
500  and  51,000.  J.  L.  Morse,  who  quotes  Gabritchevsky, 
comes  to  similar  conclusions  (Boston  City  Hospital  Re- 
ports, 1895). 

The  nervous  system  is  profoundly  affected  by  diphtheria. 
During  the  first  days  of  a  pharyngeal  diphtheria  the  soft 
palate  may  so  swell  as  to  interfere  with  respiration  and 
deglutition.  In  most  cases  an  improvement  will  take  place 
with  the  restitution  of  the  tissues  to  a  fairly  normal  size, 
and  the  local  paralysis  will  be  only  apparent.  In  other 
cases  this  apparent  paralysis  may  change  into  an  actual 
one  in  the  second  or  third  week  or  later.  Usually,  however, 
the  difficulties  of  respiration  and  deglutition  are  moderate 
— indeed,  paralysis  is  liable  to  follow  apparently  mild  cases 
in  preference  to  those  which  exhibit  a  vast  amount  of 
pharyngeal  exudation — and  after  convalescence  has  actually 
set  in  or  progressed  for  some  time  a  peculiar  array  of 
symptoms  will  make  its  appearance.  Usually  the  paralysis 
begins  in  the  throat,  the  uvula  appears  elongated,  the  soft 
palate  becomes  gradually  immovable,  articulation  is  nasal, 
deglutition  becomes  difficult,  fluids  instead  of  being  swal- 
lowed may  be  discharged  through  the  nose,  or,  when  the 
muscles  of  deglutition  are  becoming  paralyzed,  run  down 
the  larynx  and  cause  cough  and  pneumonia.  This  paraly- 
sis of  the  soft  palate  is  mostly  bilateral,  sometimes  uni- 

154 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

lateral.  A  week  or  two  after  the  beginning  of  the  pharyn- 
geal paralysis,  often  while  it  is  getting  better,  the  accom- 
modation of  ocular  movements  becomes  faulty  in  conse- 
quence of  the  symmetrical  paralysis  of  the  ciliary  nerves 
(Eulenburg).  Paralyses  of  the  internal  and  external  rec- 
tus are  less  symmetrical.  The  pupils  are  not  affected, 
other  branches  of  the  motor  oculi  and  the  abducens  but 
rarely.  Total  ophthalmoplegia  has  been  observed  in  a  few 
cases  only.  After  thousands  of  similar  observations  have 
been  made,  the  observations  of  Scheby-Buch  are  still  class- 
ical. Of  38  clinical  cases  of  paralysis  of  accommodation 
24  resulted  from  diphtheria;  of  these  20  were  located  in 
the  throat,  3  started  from  wounds,  1  from  the  vagina,  1 
from  the  skin.  There  was  no  mydriasis,  with  one  excep- 
tion. Refraction,  which  was  invariably  diminished,  and 
vision,  which  was  slightly  impaired,  became  normal  again 
with  tlie  restoration  of  health.  This  paralysis  of  accom- 
modation was  complicated  with  paralysis  of  the  palate  in 
10  cases,  in  9  cases  it  was  uncomplicated,  as  in  many 
other  instances  noticed  before  and  after  Scheby-Buch. 
Sometimes  it  would  occur  several  or  many  weeks  after  the 
appearance  of  the  pharyngeal  paraWsis. 

Next  in  the  usual  order  is  paralysis  of  the  muscles  of 
the  trunk  and  of  the  upper  and  lower  extremities,  fre- 
quently preceded  by  paraesthesia  or  anaesthesia  of  some  or 
all  the  fingers  and  the  palm  (and  other  parts  of  the  hands) 
and  feet,  also  of  other  parts  of  the  surface.  These  af- 
fections of  the  sensitive  nerves  may  be  quite  local.  I  have 
met  with  anaesthesia  of  the  trunk.  Even  the  sensory 
nerves  may  become  paralytic,  the  organ  of  taste  in  a  case 
of  Magne's ;  more  instances  may  be  found  in  my  "  Treat- 
ise," p.  101,  in  some  of  which  the  sensitive  changes  were 
such  as  to  cause  ataxia.  The  temperature  sense  has  been 
found  diminished  sometimes.  The  motor  paralysis  of  the 
extremities  may  increase  until  the  limbs  are  entirely  use- 
less for  weeks ;  as  a  peculiar  mitigation  may  be  mentioned 
the  comparative   immunity   of  the   fingers   in   many   cases. 

The  sphincters  of  the  bladder  and  of  the  anus  are  rarely 
affected,  likewise  the  muscles  of  the  larynx  and  the  respi- 
ratory muscles.     When  both  the  external  respiratory  mus- 

155 


DR.    JACOBI'S    WORKS 

cles  and  the  diaphragm  are  mildly  taken  there  is  cough, 
flapping  thoracic  respiration,  and  some  dyspnoea.  In 
severe  cases  the  patient  dies  of  apncea,  sometimes  sud- 
denly. Peristalsis  is  rarely  paralyzed;  but  a  single  case 
of  extreme  constipation  has  come  to  my  notice,  and  Bagin- 
sky,  with  his  ample  opportunities  for  observation,  has  seen 
a  few  only.  Hemiplegia  is  found  but  rarely,  and  scarcely 
at  all  in  the  very  young.  One  such  case  has  been  pub- 
lished by  J.  W.  Branan.  This  writer  says:  "  There  are 
thirty-five  cases  in  all  recorded  in  medical  literature  of 
postdiphtheritic  paralysis  of  cerebral  origin.  Six  cases 
have  come  to  autopsy;  in  one  of  these  a  hemorrhage  was 
found  in  the  internal  portion  of  the  lenticular  nucleus,  with 
destruction  of  the  neighboring  part  of  the  internal  cap- 
sule. In  the  other  five  cases  there  was  embolism  of  the 
Sylvian  artery.  ...  In  the  total  thirty-six  cases 
there  was  complete  recovery  in  four,  death  in  seven ;  in 
all  the  others  there  was  permanent  paralysis  of  greater  or 
less  extent." 

A  case  of  acute  disseminated  sclerosis  of  the  spinal  cord, 
with  neuritis,  in  diphtheria  has  been  recorded  by  S.  G. 
Henschen   (Berlin,  1896). 

The  peripheral  nerves  act  according  to  no  rule.  Some- 
times the  knee  reflexes  are  diminished  or  absent  early,  at 
other  times  late.  Reaction  of  degeneration  is  quite  common 
in  advanced  cases,  but  will  disappear  in  the  course  of  the 
general  recovery. 

In  the  beginning  of  a  diphtheria  the  prediction  that 
paralysis  will  follow  or  not  cannot  be  made.  The  very 
worst  cases  may  be  spared,  mild  ones  will  often  be  fol- 
lowed by  paralysis ;  the  latter  fact  has  been  substantiated 
in  certain  experiments  made  by  Heubner.  The  location 
of  the  diphtheritic  process  is  indiff'erent  in  regard  to  par- 
alysis; it  was  found  twenty-five  years  ago  by  Gaytton, 
Scheby-Buch,  and  myself,  also  by  Maingault  (1854,  1859), 
who  deserves  the  credit  of  having  added  most  (after 
Bretonneau)  to  our  acquaintance  with  diphtheritic  paraly- 
sis, to  be  connected  with  diphtheria  of  the  genital  organs. 
The  cause  of  paralysis  is  not  local,  but  general  and  toxic. 
In   some   seasons   and   epidemics   the   percentage   of   diph- 

156 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

theritic  paralyses  is  quite  high  (ten  to  thirty),  in  others 
low;  that  is  why  the  figures  belonging  to  a  long  series 
of  consecutive  cases  only  should  be  considered.  Now  and 
then  the  order  in  which  the  symptoms  of  paralysis  follow 
each  other  is  not  disturbed ;  but  sometimes  precisely  the 
contrary  holds  good.  Indeed,  in  many  seasons  it  is  char- 
acteristic of  diphtheritic  paralyses  to  follow  no  certain 
course,  passing  by  some  parts  of  the  body  and  attacking 
others. 

The  unexpected  occurrence  of  sudden  death  in  diph- 
theria has  sometimes  been  discussed  in  connection  with 
the  nervous  system,  at  other  times  with  the  heart.  At  all 
events  it  is  the  result  of  a  cardiac  paralysis,  due  to  a 
change  either  in  the  ganglia  or  in  the  pneumogastric  or 
in  the  sympathetic  fibres.  My  first  case  of  the  kind  was 
observed  in  1857  and  described  in  Gerhardt's  "  Handbuch," 
II.,  also  in  my  "  Treatise,"  p.  94<.  No  explanation  was 
found  at  the  autopsy.  It  occurred  before  Zenker,  Hiller, 
and  Mosler  described  parenchymatous  inflammation  and 
granular  degeneration  of  the  heart  muscle,  and  before 
the  anatomical  causes  of  defective  or  interrupted  inner- 
vation were  the  subject  of  much  study.  Afterwards  those 
changes  described  by  Zenker  in  connection  with  all  sorts 
of  infections  and  feverish  diseases,  also  amyloid  degenera- 
tion, or  heart  clots  formed  by  incompetent  muscular  action 
of  the  heart,  or  thrombi  resulting  from  sluggish  circulation 
in  distant  small  veins,  or  such  as  form  in  the  small  veins 
of  the  neck  during  the  labored  respiration  of  croup,  were 
accused  together  with  defective  or  paralyzed  innervation. 
Buhl  found  also  apoplexies  in  the  spinal  ganglia  and  in  the 
gray  substance  of  the  spinal  cord.  As  but  few  patients 
die  of  or  during  diphtheritic  paralysis,  the  opportunities 
for  making  autopsies  are  comparatively  rare.  Still,  before 
1880,  a  number  of  observations  were  made  which  compare 
favorably  with  the  results  of  modern  researches.  Buhl 
found  considerable  thickening  of  the  spinal  nerves  at  the 
junction  of  the  posterior  and  anterior  roots,  with  hemor- 
rhages and  diphtheritic  exudation  in  the  superficial  connec- 
tive tissue  in  these  places.  Oertel  described  in  the  sheath 
of  the  nerves  in  the  cerebral  and  spinal  meninges  and  in 

157 


DR.    JACOBI'S    WORKS 

the  gray  substance  of  the  cord  voluminous  nuclear  infiltra- 
tion, in  one  case  extensive  hemorrhages  in  the  spinal  men- 
inges, with  nuclear  proliferation  in  the  gray  substance  of 
the  cord;  Pierret  found  disseminated  meningitis  with  peri- 
neuritis of  the  neighboring  roots,  characterized  by  infil- 
tration of  nuclei  between  the  nerve  fibrillae;  Charcot  and 
Vulpian,  degeneration  of  the  palatine  nerves  and  fatty 
disintegration  of  the  palatine  muscles;  Dejerine,  atrophy 
of  the  anterior-roots  secondary  to  a  myelitic  degeneration 
of  the  ganglia  of  the  anterior  horns ;  also  in  two  cases 
liquefaction  of  myelin  and  loss  of  axis  cylinders  in  in- 
tramuscular nerves. 

The  changes  caused  by  diphtheria  in  the  nervous  sys- 
tem as  described  by  one  of  the  very  latest  writers  on  this 
much  discussed  subject  (John  Jenks  Thomas,  Boston  City 
Hospital,  1898)  are:  1.  Marked  parenchymatous  degen- 
eration of  the  peripheral  nerves,  sometimes  accompanied 
by  an  interstitial  process  and  by  hyperaemia  and  hemor- 
rhages; 2.  Acute  parenchymatous  degeneration  of  the 
nerve  fibres  of  the  cord  and  brain;  3.  No  changes  or  but 
slight  ones  in  the  nerve  cells ;  4.  Acute  parenchymatous 
and  interstitial  changes  in  the  muscles,  especially  in  the 
heart  muscle;  5.  Occasional  hyperaemia  or  inflammation 
or  hemorrhages  in  the  brain  cord,  or  in  rare  cases  severe 
enough  to  produce  permanent  troubles  such  as  multiple 
sclerosis  or  hemiplegia.  The  writer  adds  that  cardiac  death 
probably  takes  place  through  the  action  of  the  toxin  on  the 
cardiac  nerves.  It  is  evident  that  the  last  twenty  years 
have  not  added  much,  if  anything,  to  the  findings  of  the 
authors  of  decades  ago. 

To  this  may  be  added  the  results  of  some  late  experi- 
mentation. When  B.  MouravieiF  injected  diphtheria  toxin 
into  the  subcutaneous  tissue  or  into  the  peritoneum  of 
guinea-pigs,  acute  or  chronic  symptoms  made  their  appear- 
ance. Among  the  former  were,  in  the  ganglion  cell  of 
the  anterior  columns  of  the  spinal  cord,  peripheral  chro- 
matolysis  and  extensive  vacuolization,  but  no  anaesthesia 
nor  paralysis;  among  the  latter  were  paralysis  and  more 
neuritis  than  ganglion-cell  changes.  Extensive  peripheral 
neuritis  was  found  only  after  five  or  six  weeks. 

J58 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 


PROGNOSIS 


Epidemics  differ.  In  some,  mostly  on  account  of  the 
prevalence  of  mixed  infections,  the  morta'lity  is  high,  in 
others  it  is  low.  The  last  few  years,  not  through  the  in- 
fluence of  antitoxin  only,  have  been  decidedly  favorable, 
compared  with  many  epidemics  since  1858.  The  prognosis 
should  always  be  considered  uncertain,  if  only  for  the 
multiplicity  and  variety  of  possible  complications. 

Previous  good  health  and  vigor  do  not  insure  a  good 
prognosis.  Not  infrequently  a  system  accustomed  to  suf- 
fering, or  perhaps  immunized  against  known  and  unknown 
infections,  though  the  general  condition  may  seem  unfavor- 
able, will  escape  destruction,  while  a  robust  child  will 
soon  succumb.  That  is  why  the  rich  suffer  at  least  as  much 
as  the  poor.  But  when  the  infection  is  at  an  end,  con- 
valescence is  speedier  and  more  uninterrupted  in  the  vigor- 
ous and  well-to-do.  Probably  the  external  circumstances, 
better  air,  change  of  room,  more  thorough  disinfection  of 
rooms  if  there  was  a  previous  case,  have  a  good  deal  to 
do  with  that  result. 

Very  young  age  is  unfavorable.  The  mortality  is  great- 
est below  the  first  year  of  life,  very  large  between  the 
third  and  fourth,  low  after  the  eleventh  or  twelfth. 

Children  are  more  liable  to  suffer  than  adults.  Very 
old  people  are  almost  immune;  still  I  have  seen  a  man  of 
eighty-six  years  who  had  diphtheria  and  recovered.  Very 
young  infants  are  less  subject,  though,  when  they  are 
taken,  more  endangered  than  children  of  from  one  to  five 
years;  still  in  1880  I  reported  and  quoted  cases  of  diph- 
theria which  occurred  in  the  newly-born.  In  regard  to 
morbidity  there  appears  to  be  no  difference  as  to  sex;  mor- 
tality, however,  has  always  been  greater  in  boys.  Among 
infants  less  than  seven  or  eight  months  old  the  majority 
of  cases  occur  under  the  third  month. 

In  the  child  the  mucous  membrane  of  the  mouth,  throat, 
and  nose  is  very  soft  and  succulent;  catarrhal  and  inflam- 
matory changes  with  their  epithelial  alterations  are  fre- 
quent; the  nasal  cavities  are  narrow;  the  tonsils  are  com- 
paratively large,  indeed  they  are  but   rarely  covered  by 

159 


DR.    JACOBI'S    WORKS 

the  anterior  pillars.  Thus  invasion  and  retention  of  bacilli 
are  facilitated.  The  large  size  and  number  of  the  lymph 
vessels  predispose  to  the  absorption  of  toxins  when  formed. 
Children  who  are  able  to  creep  and  to  walk  do  not  excel 
in  cleanliness.  Their  fingers  are  equally  well  acquainted 
with  their  nares  and  their  mouths  as  with  the  dust,  dirt, 
and  parasitic  deposits  on  the  floor  of  the  room.  Their 
lips  are  tentacles  which  examine  and  lick  the  crumbs  on 
the  floor,  the  toys  in  the  dust,  many  of  which  are  of  wood 
or  of  felt  and  harborers  of  dust  and  microbes.  Their  faces 
and  hands  are  seldom  clean,  and  their  handkerchiefs  and 
towels  are  common  property. 

Such  babies  as  cannot  creep  or  walk  are  safer  because 
they  are  mostly  kept  away  from  the  floor  and  in  their 
beds;  they  are  not  in  intimate  contact  with  their  equals 
and  possible  sources  of  infection,  but  are  nursed  by  adults. 
Their  food  is  breast  milk,  or  when  artificial  it  is  boiled. 
It  was  noticed  a  long  time  ago  bj'  Home  and  Canstatt  that 
babies  at  the  breast  had  but  little  disposition  to  "  croup." 
Indeed  such  infants  are  not  so  subject  to  any  of  the  con- 
tagious and  infectious  diseases  as  older  children.  Perhaps 
Schmid  and  Pflanz  (Wiener  medizinische  JVochenschrift, 
No.  42,  1896)  are  correct  in  their  opinion  that  woman's 
milk  contains  antitoxic  materials ;  perhaps  the  immuniz- 
ing alexins  of  the  blood  serum  in  the  newly-born  are  suf- 
ficiently powerful  to  guard  against  infections  to  a  certain 
extent. 

After  the  third  month  of  life  there  is  a  copious  secre- 
tion, slightly  acid,  from  the  mouths  of  infants.  Both  its 
quantity  and  its  reaction  militate  against  microbic  invasion; 
that  is  why  at  that  period  diphtheria  is  less  common  than 
even  in  the  first  period  of  life;  even  a  common  angina  is 
not  frequent  unless  in  cold  seasons  or  after  sudden  changes 
of  temperature,  or  when  originating  from  a  nasal  catarrh 
which  is  of  frequent  occurrence. 

The  prognosis  is  favorable  when  the  aifected  surface 
is  not  extensive  and  not  in  very  intimate  connection  with 
the  lymph  circulation.  That  is  why  uncomplicated  diph- 
theria of  the  tonsils  and  local  cutaneous  diphtheria,  which 
latter  is  very  amenable  to  treatment,  are  apt  to  be  mild. 

160 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

Diphtheria  of  the  lips  and  cheeks  is  of  fair  prognosis^ 
partly  because  of  the  accessibility  of  these  parts  and  partly 
because  of  the  facility  with  which  the  natural  secretions 
macerate  and  expel  the  membranes. 

The  thickness  and  solidity  of  the  pseudomembrane  are 
not  bad  in  themselves.  Even  in  the  nose  a  massiv'e  mem- 
brane is  not  so  dangerous  as  the  thin,  flocculent,  putrid 
or  sanguinolent  discharge.  Recoveries  will  occur  though 
solid  deposits  fill  both  nares  and  have  to  be  removed  with 
probes  and  pincers.  Fetid  discharges  need  not  be  fatal, 
and  bloody  oozing  which  facilitates  the  direct  absorption 
of  toxins  into  the  circulation  may  be  successfully  treated 
with  irrigation,  as  taught  by  me  these  nearly  forty  years, 
when  conscientiously  made.  Nor  does  the  foul  and  sweet- 
ish odor  of  the  breath  justify  a  fatal  prognosis,  such  as 
Roger,  Oertel,  and  Kohts  would  pronounce.  Everything 
depends  on  the  accuracy  and  efficacy  of  the  local  disin- 
fection. Still,  nasal  diphtheria  when  not  interfered  with 
is  more  fatal  than  even  the  laryngeal  form. 

Large  swellings  of  the  lymph  bodies  near  the  affected 
surface  are  ominous.  They  are  not  so  frequent  in  uncom- 
plicated bacillary  diphtheria,  as  when  the  process  is  com- 
plicated with  staphylococcic  infection.  Streptococci  are 
still  more  dangerous — Variot's  latest  opinions  as  expressed 
in  his  "  Diphtheric  et  Serumtherapie,"  1898,  notwith- 
standing— on  account  of  the  early  septicopyaemia  which  is 
apt  to  complicate  the  case.  This  mixed  infection  is  mostly 
observed  in  diphtheria  of  the  nares  and  nasopharynx.  The 
frequently  immense  swelling  of  the  lymph  bodies  near  the 
angles  of  the  lower  jaw,  together  with  periadenitis,  is 
dangerous  and  will  very  seldom  get  well  unless  through 
the  most  careful  disinfection  of  the  original  seat  of  the 
toxic  infection.  The  outlook  improves  with  the  diminution 
in  size  of  the  lymph  nodes  and  the  accompanying  peri- 
adenitis. 

The  degree  of  danger  does  not  rise  or  fall  with  the 
temperature  of  a  case.  High  fever  attends  sometimes  a 
moderate  catarrh  of  the  pharynx,  always  a  deep-seated 
inflammation  of  a  tonsil — that  is  how  an  acute  merely  fol- 
licular   "  tonsillitis  "   ma}^   be    distinguished    from    genuine 

161 


DR.    JACOBI'S    WORKS 

diphtheria — and  a  general  catarrhal  laryngitis.  A  "  pseudo- 
croup  "  is  therefore  liahle  to  set  in  with  a  high  tempera- 
ture; a  laryngeal  diphtheria  is  not  attended  with  fever 
so  long  as  it  is  local  and  uncomplicated.  Still,  an  attack 
of  diphtheria  may  set  in  with  a  high  temperature — even 
convulsions  are  observed,  partly  occasioned  by  high  tem- 
perature, partly  by  toxin — which  will  fall  with  the  speedy 
elimination  of  the  toxin.  Low  temperatures  do  not  mean 
a  mild  character  of  the  infection;  on  the  contrary,  a  low 
temperature  may  attend  cases  of  great  gravity.  Subnormal 
temperatures  are  very  ominous ;  they  accompany  asthenia 
or  collapse.  If  a  moderate  temperature  be  followed  by 
a  sudden  rise,  this  may  signify  a  sudden  extension  of  the 
disease,  but  means  usually  the  advent  of  a  complication  in 
a  distant  organ.  A  cold,  clammy  surface  is  a  sign  of  bad 
prognostic   import. 

The  pulse  is  very  variable.  It  is  seldom  proportionate 
to  the  respiration,  being  usually  more  rapid.  So  long  as 
it  is  of  fair  volume,  and  not  too  much  out  of  proportion 
to  the  temperature  of  the  body,  the  heart  is  strong  enough; 
as  soon  as  it  becomes  rapid  and  feeble,  and  moreover  ir- 
regular, the  prognosis  becomes  more  grave.  Under  these 
circumstances  the  most  active  stimulation  is  demanded. 
In  some  instances  the  weak  heart  is  not  even  able  to  mul- 
tiply its  beats,  and  the  pulse  becomes  slow — a  most  dan- 
gerous sj'mptom.  If  a  frequent,  compressible,  and  inter- 
mittent, or  a  slow  and  intermittent  pulse  be  met  with,  to- 
gether with  a  puffy,  leaden,  apathetic,  and  cachectic  face, 
the  prognosis  is  quite  bad. 

All  of  these  symptoms  mean  a  deterioration  of  the  heart's 
action  either  by  the  direct  effect  of  toxin  on  the  nerves 
■ — a  genuine  cardio-pulmonary  paralysis — or  by  the  pres- 
ence of  clots  in  the  heart,  of  myocardial  disintegration, 
or  of  a  real  ulcerous  endocarditis.  The  latter  is,  however, 
more  commonly  the  result  of  a  streptococcal  than  of  an 
uncomplicated  bacillary  invasion. 

Affections  of  the  blood-vessel  walls  leading  to  petechiae 
or  ecchymoses  imply  a  bad,  but  not  a  fatal,  prognosis. 

The  otitis  media  accompanying  or  depending  upon  diph- 
theria is  prognostically  not  so  bad   as  that  which  is   ob- 

162 


DIPHTHERIA:     SYMPTOMS    AND     TREATMENT 

served  in  measles  or  scarlatina.  Though  deafness  is  not 
an  infrequent  outcome,  operations  are  not  so  often  de- 
manded. Meningitis  may  occur  in  the  contiguity  of  the 
tissue  or  by  lymph  communication;  in  either  case  it  orig- 
inates from  the  pharynx  or  from  the  nares,  and  often 
passes   through   the   cribriform   plate. 

Pulmonary  complications  impair  the  prognosis.  Broncho- 
or  croupous  pneumonias,  many  of  which  are  caused  by 
aspiration  of  more  or  less  septic  material,  pulmonary  hem- 
orrhages, atelectasis  caused  by  local  impediments,  and  nerv- 
ous incompetency  are  dangerous.  The  descent  of  mem- 
brane from  the  larynx  or  the  spontaneous  formation  of 
membrane  in  fibrinous  (not  always  diphtheritic)  bronchitis 
is  dangerous. 

Paralysis  of  the  laryngeal  muscles  and  the  presence 
of  pseudomembranes  in  the  larynx  ("  croup  ")  are  grave 
complications.  There  was  a  time  when  almost  every  pa- 
tient was  doomed,  viz.,  before  tracheotomy  was  introduced 
by  von  Roth,  Krackowizer,  and  Voss  into  American  prac- 
tice. Even  then  the  prejudice  against  the  operation  was 
great.  When  I  performed  it  frequently  after  I860  a 
famous  surgeon  was  known  to  ask  in  all  seriousness 
whether  Dr.  J.  did  not  cut  too  many  throats.  Its  results 
were  impaired  by  improper  procrastination  and  by  the  sep- 
tic character  of  many  of  the  epidemics.  Improved  anti- 
sepsis in  tracheotomy,  and  O'Dwyer's  intubation,  which 
has  almost  entirely  replaced  the  former  operation,  and  its 
combination  with  the  use  of  antitoxin  have  so  much  re- 
duced the  mortality  of  laryngeal  diphtheria  that  old  sta- 
tistics have  lost  all  except  their  historical  value. 

Albuminuria,  which  is  often  observed  on  the  third  or 
fourth  day  of  the  disease,  is  not  by  itself  a  grave  symptom. 
Large  quantities  of  albumin  will  sometimes  disappear  in 
a  single  day  or  in  a  few  days — as  they  will  occasionally 
do  in  other  affections  of  the  throat.  So  long  as  the  amount 
of  urine  and  the  percentage  of  urea  are  normal  or  nearly 
so,  the  danger  is  trifling.  But  the  presence  of  many  epi- 
thelial cells,  large  casts,  or  blood,  diminished  or  absent 
micturition,  and  perhaps  even  green  or  fecal  vomiting,  are 
grave  symptoms.     The  intactness  of  the  cerebral  faculties 

163 


DR.    JACOBI'S    WORKS 

during  these  attacks  of  nephritis  should  not  be  taken  as 
a  mitigating  sign.  In  many  cases  and  in  many  different 
epidemics  I  have  seen  consciousness  preserved  until  within 
a  few  minutes  before  death.  It  is  fortunate  that  actual 
nephritis  is  not  so  common  in  diphtheria  as  it  is  in  scar- 
latina; altogether  diphtheritic  nephritis  is  not  fatal  to  the 
same  extent  as  the  same  disease  when  occurring  in  scar- 
latina. 

The  average  case  of  diphtheritic  paralysis  permits  of  a 
fair  prognosis.  The  patient  generally  gets  well  in  from 
six  to  eight  weeks  under  proper  treatment.  Extensive 
neuritis  with  fatty  degeneration  of  the  myocardium  may 
paralyze  the  heart;  paralysis  of  the  pharynx  and  of  the 
vestibule  of  the  pharynx  may  lead  to  aspiration  pneumonia; 
ciliary  paralysis  may  remain  permanent;  that  of  the  respi- 
ratory muscles  may  cause  apnoea  and  death,  and  that  of 
the  sphincters  of  the  anus  and  of  the  bladder,  in  the  rare 
cases  in  which  they  have  been  observed,  or  of  the  spinal 
cord  (tabes,  hemiplegia)  may  last  forever.  That  is  why 
the  prognosis  in  every  case  of  diphtheria  should  be  a 
guarded  one  until  recovery  is  found  to  be  complete. 

TREATMENT 

Preventive  Treatment. — Prevention  is  partly  the  busi- 
ness of  the  physician,  but  should  be  mostly  that  of  the  in- 
dividual, or  of  the  complex  of  individuals,  viz.,  the  town, 
state,  or  nation.  A  child  sick  with  diphtheria  must  be  iso- 
lated, though  the  case  appear  ever  so  mild,  and  if  possible 
the  well  children  should  be  sent  out  of  the  house.  If  that 
be  impossible,  let  them  remain  outside,  in  the  open  air,  as 
long  as  feasible;  let  them  sleep  in  the  most  distant  part  of 
the  dwelling  with  open  bedroom  windows  during  the  night, 
and  let  their  throats  be  examined  every  day.  The  watchful 
eye  of  an  intelligent  father  or  mother  may  discover  devi- 
ations from  the  norm,  so  that  the  physician  can  be  noti- 
fied. Let  the  temperature  of  the  well  children  be  taken 
once  a  day,  in  the  rectum.  The  expenditures  of  a  few  min- 
utes of  a  mother's  time  will  be  repaid  by  the  discovery  of  a 
slight  anomaly,  which  may  require  the  presence  of  the  phy- 

164 


DIPHTHERIA:     SYMPTOMS    AND     TREATMENT 

sician.  Happily,  there  are  many  mothers  who  keep  and 
value  a  self-registering  thermometer  as  an  important  addi- 
tion to  their  household  articles.  The  attendant  upon  a  case 
of  diphtheria  should  not  come  in  contact  with  the  rest  of 
the  family,  particularly  the  children,  for  the  poison  may  be 
carried,  although  the  carrier  remains  well  or  apparently 
well.  The  physician  should  see  the  well  or  suspected  child 
before  he  visits  the  patient.  Though  not  in  protracted  con- 
tact with  their  patients,  medical  men  should  use  reasonable 
caution.  Those  visiting  a  diphtheria  ward  or  a  diphtheria 
patient  should  wear  a  clean  linen  cap  or  coat,  or  a  rubber 
garment.  E.  M.  Buckingham  (Boston  Medical  and  Sur- 
gical Journal,  February  1  Ith,  1895)  disinfects  the  soles 
of  his  boots  after  leaving  his  ward,  and  soaks  his  hands 
and  wrists  in  a  solution  (1:1000)  of  corrosive  sublimate 
which  is  allowed  to  dry.  Unnecessary  petting  of  the  pa- 
tient on  the  part  of  the  well  ought  to  be  avoided,  kissing 
must  be  forbidden,  the  bedclothing  and  linen  are  to  be 
changed  often  and  disinfected,  and  the  air  must  be  kept 
cool  and  often   changed. 

During  the  epidemic  of  diphtheria,  and  in  families 
stricken  with  diphtheria,  the  boiling  of  water  and  milk 
should  be  enforced. 

The  well  or  apparently  well  children  of  a  family  in 
which  there  is  diphtheria  must  not  go  to  school  or  to 
church.  The  former  necessity  is  beginning  to  be  recog- 
nized by  the  authorities  and  teachers  and  also,  in  con- 
sequence of  compulsion,  by  parents;  but  I  have  seen  chil- 
dren after  being  excluded  from  the  schools  taken  to  church. 
Schools  ought  to  be  closed  entirely  when  many  cases  have 
occurred.  Even  when  the  school  children  have  not  been 
extensively  affected,  but  a  diphtheria  epidemic  has  com- 
menced in  earnest,  it  will  be  better  to  close  the  schools 
for  a  time.  If  that  be  not  advisable,  the  teacher  ought 
to  be  instructed  to  inspect  throats,  and  directed  to  ex- 
amine every  child  in  the  morning,  and  send  home  every 
one  barely  suspected.  This  is  not  superfluous  even  where 
a  regular  medical  inspection  has  been  introduced,  as  in 
New   York   City. 

The  Board  of  Health  of  the  State  of  New  Jersey  has 

165 


DR.    JACOBI'S    WORKS 

issued  the  following  school  regulations,  which,  if  obeyed, 
cannot  fail  to  have  a  good  influence  and  should  be  adopted 
by  similar  authorities. 

"  I.  Each  day  during  the  prevalence  of  infectious  dis- 
ease, after  the  school  is  dismissed,  the  janitor  is  to  scrub 
with  warm  water,  soap,  and  a  stiff  scrubbing-brush  all 
parts  of  doors,  casings,  and  other  woodwork  which  can  be 
touched  by  the  hands  of  children.  II.  The  floor  should 
be  in  good  repair  and  without  open  cracks  or  crevices. 
It  should  be  sprinkled  with  clean  water  daily  before  being 
swept.  III.  Lead  pencils  (there  should  be  no  slates) 
should  every  day  be  immersed  in  a  five-per-cent.  solution 
(1:  20)  of  carbolic  acid  and  wiped  dry.  IV.  Books  which 
have  been  used  by  a  pupil  who  is  suff"ering  from  any  one 
of  the  communicable  diseases  should  be  destroyed  by  fire 
or  they  may  be  treated  by  exposure  to  formaldehyde  gas. 
V.  During  each  vacation  the  walls  and  woodwork  should 
be  wetted  with  a  solution  of  bichloride  of  mercury 
(1:  1000)  and  the  windows  should  be  kept  open  to  admit 
great  floods  of  sunlight  and  pure  air.  VI.  Water  coolers 
are  unclean  and  unnecessary.  They  should  not  be  al- 
lowed in  school  buildings.  When  practicable  drinking 
fountains,  consisting  of  a  jet  of  water  rising  from  the 
center  of  a  piece  of  marble,  requiring  no  cups,  should  be 
supplied.  VII.  Individual  seats  and  desks  should  be  pro- 
vided in  every  school.  VIII.  Light  and  airy  cloakrooms 
should  always  be  provided,  and  hooks  should  be  so  sepa- 
rated that  the  garments  of  diff"erent  pupils  will  not  come 
into   contact." 

In  times  of  an  epidemic,  every  public  place,  theatre, 
ballroom,  dining-hall,  tavern,  should  be  treated  like  a  hos- 
pital. Where  there  is  a  large  conflux  of  people,  there 
are  certainly  many  who  carry  the  disease  with  them.  The 
spitting  nuisance  should  be  persistently  suppressed.  Dis- 
infection at  regular  intervals  should  be  enforced  by  the 
authorities.  Public  vehicles  must  be  so  treated.  That 
they  should  be  disinfected  after  a  case  of  smallpox  has 
been  carried  in  them  is  deemed  quite  natural.  Hardly  a 
livery  stable-keeper  would  be  found  who  would  not  be 
anxious  to  destroy  the  possibility  of  infection  in   any  of 

166 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

his  coaches.  He  must  learn  that  diphtheria  is,  or  may  be, 
as  dangerous  a  passenger  as  variola.  And  what  is  valid 
in  the  case  of  a  hack  is  more  so  in  that  of  railroad  cars, 
whether  emigrant  or  Pullman.  They  ought  to  be  thor- 
oughly disinfected  in  times  of  an  epidemic,  at  regular  in- 
tervals, for  the  highroads  of  travel  have  always  been  those 
of  epidemic  disease,  and  railroad  officers  and  their  families 
have  often  been  the  first  victims, of  the  imported  scourge. 
Can  this  be  accomplished?  Will  not  railroad  companies 
resist  a  plan  of  regular  disinfection  because  of  its  ex- 
pensiveness?  Will  there  not  be  an  outcry  against  this 
despotic  violation  of  the  rights  of  the  citizen,  and  the 
independence  of  the  moneybag?  Certainly.  But  that  also 
happened  when  municipal  authorities  began  to  compel  par- 
ents to  keep  their  children  at  home  when  there  were  con- 
tagious diseases  in  the  family,  and  when  a  smallpox  pa- 
tient was  arrested  because  of  endangering  the  passengers 
in  a  public  vehicle.  In  such  cases,  it  is  not  society  that 
tyrannizes  the  individual;  it  is  the  individual  that  endangers 
society.  And  society  begins  at  last,  even  in  America,  to 
believe  in  the  rights  of  the  commonwealth,  as  compared 
with  the  exclusive  rights  of  the  democratic  enemy  of  all 
the  rest.  The  establishment  of  state  and  national  boards 
of  health  proves  that  the  narrow-minded  theories  of  the 
strict  constructionists  have  not  only  disappeared  from  our 
politics,  but  also  from  the  conscience  and  intellect  of 
society. 

As  stated  above,  every  case  of  diphtheria  demands  iso- 
lation, during  the  winter  on  the  upper  floor  of  the  dwell- 
ing; the  windows  should  be  open  as  much  as  possible,  the 
furniture  of  the  sick-room  reduced  to  the  least  possible 
quantity,  the  room  changed  if  possible  every  few  days, 
and  the  bedding  renewed  frequently. 

To  what  extent  the  infecting  substance  may  cling  to 
surroundings  is  best  shown  by  the  cases  of  diphtheria 
springing  up  in  premises  which  had  not  seen  diphtheria 
for  a  long  time,  but  had  not  been  interfered  with ;  and  best, 
perhaps,  by  a  series  of  observations  of  autoinfection.  When 
a  diphtheritic  patient  has  been  in  a  room  for  some  time, 
the  room,  bedding,  curtains,  and  carpets  are  infected;  the 

167 


DR.    JACOBI'S    WORKS 

child  is  getting  better,  has  a  new  attack,  may  again  im- 
prove, and  is  again  stricken  down.  I  have  seen  some  of 
these  children  die;  but  also  others  who  improved  immedi- 
ately after  having  been  removed  from  that  room  or  that 
house.  If  in  any  way  possible,  a  child  with  dii^htheria 
ought  to  change  its  room  and  bed  every  few  days. 

The  sick  in  crowded  houses  and  quarters  ought  to  be 
transferred  to  a  special  hospital,  which  ought  not  to  be 
too  large.  The  Willard  Parker  Hospital  of  New  York, 
with  its  seventy  beds  for  scarla,tina  and  diphtheria,  estab- 
lished through  the  combined  efforts  of  the  medical  profes- 
sion,^ is  in  that  respect  a  praiseworthy  example.  The  large 
amount  of  good  it  is  doing  would  grow  in  geometrical  pro- 
gression if  there  were,  as  there  ought  to  be  in  a  large  and 
ambitious  metropolis,  half  a  dozen  institutions  of  the  same 
class,  not  only  for  the  poor,  but  for  the  well-to-do  also, 
both  towns-people  and  strangers.  I  have  advocated,  for 
dozens  of  years,  the  erection  of  a  hospital  for  the  accom- 
modation of  infectious  diseases  breaking  out  among  the 
thousands  of  strangers  staying  in  New  York  City  at  all 
times.  As  long  as  there  is  no  place  for  them  to  go  to, 
the  cases  of  scarlatina,  diphtheria,  etc.,  are  hidden  in  the 
boarding-houses  and  hotels,  and  are  infecting  the  popula- 
tion at  large.  It  is  but  a  few  years  since  a  movement  for 
the  establishment  of  such  an  institution  was  begun;  the 
hospital  for  scarlatina  and  diphtheria  was  finally  estab- 
lished a  year  ago. 

When  diphtheria  breaks  out  in  a  house,  either  private 
or  tenement  with  no  facility  for  isolation,  and  where  there 
is  no  hospital  in  which  to  seek  refuge,  the  well  should  be 
removed  to  a  healthy  place;  in  large  cities,  temporary 
homes  ought  to  be  provided  for  that  purpose,  to  benefit 
the  children  of  the  poor.  If  the  rich  would  but  remember 
that  their  children  will  be  affected  through  the  many  links 
between  them  and  the  poor  (servants,  messengers,  schools, 
dresses  brought  home  from  the  tailor  or  seamstress,  or  pur- 
chased in  the  stylish   and  expensive  establishments  which 

5  See  my  presidential  address  before  the  Medical  Society  of 
the  State  of  New  York  in  the  Transactions  of  1882.  [Vol.  vii  of 
the  present  edition  of  Dr.  Jacobi's  Works.] 

168 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

give  out  the  work  to  tenement  working-people,  and  toil- 
ers in  sweat  shops),  their  very  egotism  would  compel  them 
to  do  in  their  own  interest  what  the  humanitarian  instinct 
may  not  suggest  to  them. 

Prevention  can  accomplish  a  great  deal  for  the  individ- 
ual. Diphtheria  will  not,  as  a  rule,  attack  a  healtliy  in- 
tegument, either  cutis  or  mucous  membrane.  The  best 
preventive  is,  therefore,  to  keep  the  mucous  membrane  in 
a  healthy  condition,  as  I  have  tried  to  practise  and  teach 
these  forty  years.  Catarrh  of  the  mouth,  pharynx,  and 
nose  must  be  treated  in  time.  Many  a  chronic  nasal 
catarrh,  with  big  lymph  bodies  round  the  neck,  requires 
sometimes  for  its  cure  but  two  or  three  daily  warm  salt- 
water irrigations  (1:130)  of  the  nose,  and  besides,  if 
the  children  be  large  enough  to  do  so,  gargling.  The 
addition  of  one  per  cent,  of  alum  or  less  will  often 
be  found  useful.  This  treatment,  however,  must  be  con- 
tinued for  many  months,  and  may  require  years.  Still, 
there  is  no  hardship  in  it,  and  no  excuse  for  its  omission. 
A.  Caille's  many  eloquent  appeals  have  done  much  to  popu- 
larize it.  The  nasal  spray  of  a  solution  of  nitrate  of  sil- 
ver, 1 :  500-1,000,  when  there  are  erosions,  will  accelerate 
the  cure.  Its  application  should  be  repeated  every  day  or 
every  few  days  for  some  time. 

Krieger  regarded  the  inhalation  of  dry  (particularly  fur- 
nace) air  as  the  main  predisposing  cause  of  diphtheria  on 
account  of  its  deteriorating  influence  on  epithelia.  For  a 
similar  reason  C.  Briihl  and  E.  Jahr  demand  that  both 
heating  apparatuses  and  ventilators  should  be  so  arranged 
and  so  ample  as  to  equalize  the  humidity  in  winter  and 
summer,  especially  in  bedrooms  and  in  schools.  The  chil- 
dren should  be  hardened  and  strengthened  by  the  use  of 
cold  water.  Not  only  houses  but  whole  districts  may  be 
treated  on  the  same  principles.  Favorable  climatological 
changes  have  often  been  produced  by  irrigation,  the  estab- 
lishment of  new  channels,  of  water-courses,  and  intelli- 
gent forestry.  But  it  would  cost  millions  to  save  lives 
wholesale;  and  all  these  millions  are  required  to  destroy 
lives  wholesale  in  haphazard  wars.  In  accordance  with 
the  above-mentioned  principles  authors  emphasize  the  neces- 

169 


DR.    JACOBFS    WORKS 

sity  of  keeping  the  mucous  membranes  moist^  and  of  pre- 
venting fissures  and  disintegration  of  the  epithelia.  In 
the  last  two  or  three  decades  the  latter  advice  has  been 
insisted  upon  by  all  those  who  had  waked  up  to  the  neces- 
sity of  prevention.  Among  others  C.  G.  Rothe  (1884)  ad- 
vised besides  hygienic  measures  the  frequent  use  by  all  the 
inmates  of  a  stricken  house  of  a  gargle  consisting  of  car- 
bolic acid,  alcohol,  tincture  of  iodine,  glycerin,  and  water; 
also  the  use  by  all  children  of  a  school  of  a  solution  of 
thymol  (1:1,000)  and  cyanide  of  mercury  for  the  very 
mildest  affections.  In  connection  with  such  advice  one 
remark  will  always  be  in  order,  viz.,  that  medicinal  gargles 
and  irrigations  should  not  be  as  unpalatable  and  malodor- 
ous as  they  can  possibly  be  made;  children  should  not  be 
made  to  look  upon  preventive  measures  as  a  punishment. 

It  was  not  always  good-will  and  intelligence  or  knowl- 
edge that  dictated  either  reasoning  or  recommendations. 
There  is  J.  Renan  for  instance,  who  in  his  "  Diphtheric," 
Paris,  1889,  recommended  the  free  use,  among  preventives, 
of  sulphurous  acid  and  turpentine.  Altogether  the  litera- 
ture of  diphtheria  is  not  free  even  from  religious  and 
political  bias.  According  to  Renan's  monarchistic  prej- 
udices the  inferiority  of  preventive  practice  in  (republican) 
France  is  due  to  the  changeability  of  its  government. 
According  to  that  theory  Turkey  and  Russia  would  excel 
in  preventive  medicine,  for — barring  occasional  assassina- 
tions— their  governments  are  stable  enough. 

For  its  salutary  effect  on  the  mucous  membrane  of  the 
mouth,  chlorate  of  potassium  or  of  sodium,  which  is  still 
claimed  by  some  to  be  a  specific  in  diphtheria,  or  almost 
so,  is  counted  by  me  among  the  preventive  remedies.  If 
it  be  anything  more,  it  is  an  adjuvant  only.  It  exhibits 
its  best  effects  in  the  catarrhal  and  ulcerous  condition  of 
the  oral  cavity.  In  diphtheria  it  preserves  the  mucous 
membrane  in  a  healthy  condition  or  restores  it  to  health. 
Thus  it  prevents  the  diphtheritic  process   from  spreading. 

Diphtheria  is  seldom  observed  on  healthy  or  apparently 
healthy  tissues.  The  pseudomembrane  is  mostly  surrounded 
by  a  sore,  hyperaemic,  oedematous  mucous  membrane,  to 
which  it  will  then  extend.      Indeed,  this   hyperaemia   pre- 

170 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

cedes  the  appearance  of  the  diphtheritic  exudation  in  al- 
most every  case.  The  exceptions  to  this  rule  are  formed 
by  those  cases  in  which  the  virus  may  take  root  in  the  in- 
terstices, pointed  out  by  Stoehr,  between  the  normal 
tonsillar  epithelia.  Indeed,  many  cases  of  throat  disease 
occurring  during  the  prevalence  of  an  epidemic  of  diph- 
theria are  but  cases  of  pharyngitis  which  develop  only 
under  favorable  circumstances  into  diphtheria.  These 
throat  diseases  are  so  very  frequent  during  the  reign  of 
an  epidemic  that  in  my  first  paper  on  diphtheria,  while 
reporting  two  hundred  cases  of  genuine  diphtheria,  I 
mentioned  besides  one  hundred  and  eighty-five  of  pharyn- 
gitis without  a  visible  membrane. 

These  cases  of  pharyngitis,  and  those  of  stomatitis  and 
pharyngitis  which  accompany  the  presence  of  membranes, 
are  benefited  by  the  local  and  general  effect  of  potassic 
chlorate.  When  the  surrounding  parts  are  healthy  or  re- 
turn to  health,  the  pseudomembrane  remains  circumscribed. 
The  generally  benign  character  of  purely  tonsillar  diph- 
theria, which  is  apt  to  run  its  full  course  in  from  four  to 
six  days,  has  in  this  manner  contributed  to  secure  to 
chlorate  of  potassium  the  undeserved  reputation  of  being 
a  remedy,  the  remedy,  in  diphtheria.  The  dose  of  the  salt 
must  not  be  larger,  in  twenty-four  hours,  than  gr.  xv. 
(1  gm.)  for  an  infant  a  year  old,  not  over  gr.  xx.  or  xxx. 
(1.5-2  gm.)  for  a  child  from  three  to  five  years.  An  adult 
should  not  take  more  than  3  iss.  (6  gm.)  daily.  These 
amounts  must  not  be  given  in  a  few  large  doses,  but  in 
frequent  doses  and  at  short  intervals.  A  solution  of  1 
part  in  60  may  be  given  in  doses  of  a  teaspoonful  every 
hour  or  half  a  teaspoonful  every  half-hour  in  the  case  of 
a  baby  one  or  two  years  old. 

It  is  not  too  late  yet  to  raise  a  warning  voice  against 
the  use  of  larger  doses.  Simple  truths  in  practical  medi- 
cine do  more  than  merely  bear  repetition — they  require 
it.  For  though  the  cases  of  actual  chlorate  of  potassium 
poisoning  are  no  longer  isolated,  and  ought  to  be  gen- 
erally known,  fatal  accidents  are  still  ocurring  even  in 
the  practice  of  physicians.  When  I  experimented  on  my- 
self  with  half-ounce   doses,   forty   years   ago,   the   results 

171 


DR.    JACOBI'S    WORKS 

were  some  gastric  and  intense  renal  irritation.  The  same 
were  experienced  by  Fountain,  of  Davenport,  Iowa,  whose 
death  from  an  ounce  (30  gm.)  of  the  salt  has  been  imr 
pressively  described  in  Alfred  Stille's  "  Materia  Medica," 
from  which  I  have  quoted  in  my  "  Treatise  on  Diphtheria." 
His  death  from  chlorate  of  potassium  induced  me  to  warn 
against  large  doses  in  my  lectures  as  early  as  I860.  In 
my  contribution  to  Gerhardt's  "  Handbuch  der  Kinder- 
krankheiten,"  Vol.  II.,  1877,  I  spoke  of  a  series  of  cases 
known  to  me  personally.  In  a  paper  read  before  the 
Medical  Society  of  the  State  of  New  York  (Medical  Rec- 
ord, March  15th,  1879)  I  treated  of  the  subject  mono- 
graphically,  and  alluded  to  the  dangers  attending  the  pro- 
miscuous use  of  the  drug,  which  had  even  then  descended 
into  the  ranks  of  domestic  remedies;  and  finally,  in  my 
"  Treatise  on  Diphtheria,"  I  collected  all  my  cases  and  the 
few  then  recorded  by  others.  Since  that  time  numerous 
instances  have  been  reported.  Death  probabh'  occurs  from 
methaemoglobinuria  (as  shown  by  Marchand,  of  Halle,  in 
1879),  produced  by  the  presence  of  the  poison  in  the  blood, 
and  by  consecutive  nephritis. 

The  conscientious  use  of  salt  water  as  a  preventive  meas- 
ure will  prove  more  successful — when  combined  with  the 
daily  cold-water  bath  or  ablution — than  all  the  offensive 
smells  and  tastes  which  have  been  recommended. 

Large  tonsils  should  be  resected  and  adenoid  growths 
removed  while  there  is  no  diphtheria ;  for  during  an  epi- 
demic every  wound  in  the  mouth  is  liable  to  become  diph- 
theritic, and  such  operations  ought  to  be  postponed,  if 
feasible.  The  scooping  out  of  the  tonsils,  for  whatever 
cause,  I  have  given  up  since  I  became  better  acquainted 
with  the  use,  under  cocaine,  of  the  galvanocautery.  From 
one  to  four  applications  to  each  side  are  usually  sufficient 
for  every  case  of  enlarged  tonsils  or  chronic  lacunar  or 
deep-seated  follicular  amygdalitis  ("tonsillitis").  It  is 
advisable  to  cauterize  but  one  side  at  a  time,  in  order  to 
avoid  inconvenience  in  swallowing  afterwards,  and  to  burn 
the  surface  inward.  Cauterization  of  the  center  of  the 
tonsils  may  result  in  swelling,  pain,  and  suppuration,  un- 
less  the  cautery  is   carried  entirely  to  the   surface;  that 

172 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

means,  the  scurf  must  be  on,  or  extend  to,  the  surface,  and 
not  remain  inside  the  tissue.  Another  precaution  is  to 
apph^  the  burner  cold,  press  it  on,  and  then  heat.  The 
actual  cautery  is,  however,  not  always  required;  a  strong 
hook,  without  or  with  Gleitsmann's  cutting  edge,  bent  to 
a  convenient  angle,  introduced  into  a  follicular  fistula,  and 
torn  through  the  superjacent  tissue,  will  also  cause  cicatri- 
zation and  a  cure. 

Nasal  catarrh  and  proliferation  of  the  mucous  and  sub- 
mucous tissues  may  require  appropriate  treatment  with  the 
electrocautery  in  many  chronic  cases,  but  the  cases  which 
demand  it  are  less  frequent  than  those  in  which  the  tonsils 
need  correction. 

The  presence  of  lymph-node  swellings  round  the  neck 
should  not  be  tolerated.  They  and  the  oral  and  nasal 
mucous  membranes  affect  each  other  mutually.  Most  of 
them  could  be  prevented  if  every  eczema  of  the  head  and 
face,  everj'^  stomatitis  and  rhinitis  resulting  from  unclean- 
liness,  injury,  or  infection,  were  relieved  at  once.  Pains- 
taking care  of  that  kind  would  prevent  many  a  case  of 
diphtheria,  glandular  suppuration,  deformity,  or  pulmon- 
ary consumption. 

Prevention  of  diphtheria  by  immunizing  doses  of  anti- 
toxin  appears  to  be  possible,  but  the  effect  does  not  last 
beyond  a  few  weeks. 

Slawyk's  report,  published  in  the  Deutsche  Medicinische 
Wochenschrift,  No.  6,  1898,  is  very  interesting.  In  Hueb- 
ner's  division  of  the  Charite  Hospital  of  Berlin  relapses 
or  endemic  infections  were  quite  common  in  spite  of  care- 
ful preventive  measures  until  immunization  by  antitoxin 
was  resorted  to.  The  doses,  of  two  hundred  units  con- 
tained in  8  c.c.  each,  were  repeated  every  three  weeks. 
In  this  way  the  place  remained  free  of  diphtheria.  As  a 
matter  of  experiment  immunization  was  discontinued  on 
October  1st,  1897-  Three  cases  of  diphtheria,  one  of 
which  terminated  fatally,  occurred  in  the  first  part  of 
November.  The  preventive  injections  were  then  made 
again,  and  during  the  following  two  and  a  half  months, 
up  to  the  time  the  report  was  published,  no  new  case  had 
been   observed.      Neither  early   age  nor   any   complicating 

173 


DR.    JACOBI'S    WORKS 

disease  appeared  to  furnish  a  contraindication  to  the  in- 
jections. 

Similar  results  have  been  obtained  in  New  York  and 
elsewhere.  The  duration  of  the  immunity  so  obtained  is, 
however,  limited.  It  has  frequently  been  observed  t!;at  a 
dose  of  from  two  to  four  hundred  units  of  antitoxin,  when 
given  for  immunizing  purposes,  appeared  to  be  successful, 
until  the  child  was  taken  with  diphtheria  thirty  or  forty 
days  after  the  injection. 

In  connection  with  the  preventive  measures  detailed 
above,  I  now  add,  though  they  be  in  part  a  repetition  of 
what  has  been  said,  the  regulations  of  the  New  York 
Health  Department  which  have  been  in  force  for  some 
time.     They  are  clear,  concise,  and  to  the  point. 

"  If  possible,  one  attendant  should  take  the  entire  care 
of  the  sick  person,  and  no  one  else  besides  the  physician 
should  be  allowed  to  enter  the  sick-room.  The  attendant 
should  have  no  communication  with  the  rest  of  the  family. 
The  members  of  the  family  should  not  receive  or  make 
visits  during  the  illness. 

"  The  discharges  from  the  nose  and  mouth  must  be 
received  on  handkerchiefs  or  cloths,  which  should  be  at 
once  immersed  in  a  carbolic  solution  (made  by  dissolv- 
ing six  ounces  of  pure  carbolic  acid  in  one  gallon  of  hot 
water,  which  may  be  diluted  with  an  equal  quantity  of 
water).  All  handkerchiefs,  cloths,  towels,  napkins,  bed 
linen,  personal  clothing,  night  clothes,  etc.,  that  have  come 
in  contact  in  any  way  with  the  sick  person,  after 
use  should  be  immediately  immersed  without  removal  from 
the  room  in  the  above  solution.  These  should  be  Sf)aked 
for  two  or  three  hours,  and  then  boiled  in  water  or  soap- 
suds for  one  hour. 

"  In  diphtheria  and  scarlet  fever,  great  care  should  be 
taken  in  making  applications  to  the  throat  or  nose,  that 
the  discharges  from  them  in  the  act  of  coughing  are  not 
thrown  into  the  face  or  on  the  clothing  of  the  person  mak- 
ing the  applications,  as  in  this  way  the  disease  is  likely 
to  be  caught. 

"  The   hands   of  the  attendant  should   always   be  thor- 

174 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

oughly  disinfected  by  washing  in  the  carbolic  solution, 
and  then  in  soapsuds,  after  making  applications  to  the 
throat  or  nose,  and  before  eating. 

"  Surfaces  of  any  kind  soiled  by  the  discharges  should 
be   immediately   flooded   with   the  carbolic   solution. 

"  Plates,  cups,  glasses,  knives,  forks,  spoons,  etc.,  used 
by  the  sick  person  for  eating  and  drinking  must  be  kept 
for  his  especial  use,  and  under  no  circumstances  removed 
from  the  room  or  mixed  with  similar  utensils  used  by 
others,  but  must  be  washed  in  the  room  in  the  carbolic 
solution  and  then  in  hot  soapsuds.  After  use  the  soap- 
suds should  be  thrown  into  the  water-closet  and  the  vessel 
which  contained  it  should  be  washed  in  the  carbolic  so- 
lution. 

"  The  room  occupied  by  the  sick  person  should  be  thor- 
oughly aired  several  times  daily,  and  swept  frequenllj-, 
after  scattering  wet  newspapers,  sawdust,  or  tea  leaves  on 
the  floor  to  prevent  the  dust  from  rising.  After  sweeping, 
the  dust  upon  the  woodwork  and  furniture  should  be  re- 
moved with  damp  cloths.  The  sweepings  should  be  burned, 
and  the  cloths  soaked  in  the  carbolic  solution.  In  cold 
weather,  the  sick  person  should  be  protected  from  draughts 
of  air  by  a  sheet  or  blanket  thrown  over  his  head  while 
the  room  is  being  aired. 

"  When  the  contagious  nature  of  the  disease  is  rec- 
ognized within  a  short  time  after  the  beginning  of  the 
illness,  after  the  approval  of  the  Health  Department  in- 
spector, it  is  advised  that  all  articles  of  furniture  not  neces- 
sary for  immediate  use  in  the  care  of  the  sick  person, 
especially  upholstered  furniture,  carpets,  and  curtains, 
should  be  removed  from  the  sick-room. 

"  When  the  patient  has  recovered  from  any  one  of  these 
diseases  the  entire  body  should  be  bathed  and  the  hair 
washed  with  hot  soapsuds  and  the  patient  should  be  dressed 
in  clean  clothes  (which  have  not  been  in  the  room  during 
the  sickness)  and  removed  from  the  room.  Then  the 
Health  Department  should  be  immediately  notified,  and 
disinfectors  will  be  sent  to  disinfect  the  room,  bedding, 
clothing,  etc.;  and  under  no  conditions  should  it  be  again 

175 


DR.    JACOBI'S    WORKS 

entered  or  occupied  until  it  has  been  thoroughly  disin- 
fected. Nothing  used  in  the  room  during  the  sickness 
should  be   removed   until  this   has   been   done. 

"  The  attendant^  and  any  one  who  has  assisted  in  car- 
ing for  the  sick  person,  should  also  take  a  bath,  wash 
the  hair,  and  put  on  clean  clothes,  before  mingling  with 
the  family  or  other  people  after  the  recovery  of  tlie  pa- 
tient. The  clothes  worn  in  the  sick-room  should  be  left 
there,  to  be  disinfected  with  the  room  and  its  contents 
by  the   Health  Department." 

Among  the  disinfectants  employed  to  advantage  in  dwell- 
ings formalin  has  of  late  taken  a  high  rank.  A  spray  of 
a  two-per-cent.  solution  has  been  found  available.  From 
60  to  70  c.c.  of  dissolved  concentrated  formalin  is  believed 
to  be  sufficient  for  the  space  of  one  cubic  meter  (thirty 
cubic  feet).  One  gram  of  formaldehyde  evaporated  from 
Schering's  lamp  or  other  apparatus  renders  the  same  ser- 
vice; or  the  substance  may  be  allowed  to  evaporate  grad- 
ually. Meanwhile  the  eyes  should  be  protected  by  glasses, 
the  nose  by  a  mask,  the  hands  by  vaseline.  Still,  if 
Symansky  be  correct  {Zeitschrift  fiir  Hygiene,  etc.,  xxviii., 
1898,  p.  237),  even  formalin  leaves  much  to  be  desired. 
He  claims,  while  mentioning  in  its  favor  that  it  does  not 
injure  clothing  and  furniture,  with  the  exception  of  chang- 
ing red  aniline  dyes  into  purple,  that  its  best  effect  is  ob- 
tained at  high  temperatures  and  in  dry  atmospheres,  and 
that  it  has  but  little  penetration  and  destroys  no  spores, 
and  for  that  reason  yields   no  absolutely  safe  results. 

LOCAL    TREATMENT 

The  local  remedies  employed  have  been  used  for  the 
purpose  of  either  directly  destroying  the  pseudomembrane, 
such  as  nitrate  of  silver,  carbolic  acid,  the  actual  cautery; 
or  to  dissolve  them,  such  as  the  alkaline  carbonates,  the 
chlorides,  steam,  papayotin;  or  to  act  as  astringents,  such 
as  limewater  and  the  chloride  and  subsulphate  of  iron; 
or  to  disinfect,  such  as  the  potassic  chlorate,  chloral  hy- 
drate, turpentine,  carbolic  acid,  mercury,  sulphur,  bromine, 
iodine,  iodoform,  chlorine  water,   and   peroxide   of   hydro- 

176 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

gen.  The  methods  of  application  have  been  either  local 
administration  by  the  attendant,  or  washes  and  gargles, 
sprays,  injections,  or  inhalations. 

The  local  treatment  of  the  mouth  and  throat  has  two 
indications ;  first,  to  maintain  or  restore  a  healthy  condi- 
tion of  the  mucous  membrane  of  the  cavities;  second,  to 
influence  the  diseased  surface.  Gargles  in  any  shape  will 
reach  the  oral  cavity  only.  They  never  touch  anything 
bej^ond  the  anterior  pillars  of  the  soft  palate,  and  seldom 
more  than  a  small  part  of  the  tonsil.  The  gargles  with 
potassic  chlorate,  or  with  the  sodic  benzoate  or  biborate 
have  only  a  preventive,  not  a  curative,  effect;  still,  they 
ought  not  to  be  neglected  when  the  children  are  old  enough 
to  use  them.  Mild  solutions  of  the  above  salts  may  also 
be  introduced  into  the  mouth  of  babies  from  time  to  time 
by  means  of  a  brush  or  a  pipette.  Local  applications  to 
the  throat,  even  where  they  are  possible,  ought  not  to  be 
made  with  powders.  They  are  apt  to  nauseate  and  pro- 
duce vomiting  by  their  mere  contact.  Even  powders  for 
internal  administration  require  careful  mixing  with  water, 
for  they  are  liable  to  irritate  the  throat;  thus,  the  direct 
application  of  calomel,  of  the  oxide  of  mercury,  or  of  sul- 
phur ought  to  be  avoided.  Applications  of  substances  with 
bad  taste  or  those  that  give  pain  must  not  be  made,  be- 
cause the  struggling  and  consecutive  exhaustion  of  the  pa- 
tient will  do  more  harm  than  the  remedy  will  do  good. 
That  is  so  with  a  number  of  substances,  particularly  with 
the  chloral  hj^drate,  and  even  with  the  chloride  of  sodium 
which  has  been  recommended,  like  a  hundred  other  things, 
as  a  local  application  to  the  pseudomembrane  of  the 
tonsil. 

In  diphtheria  the  danger  arises  first  from  suffocation. 
That  can  be  easily  recognized,  and  the  indications  for 
the  treatment  by  mechanical  means — that  is,  intubation  or 
tracheotomy — are  readily  found.  These  are  the  cases  in 
which  repeated  fumigations  with  gr.  vii.-xv.  (0.5-1  gm.) 
of  calomel,  under  a  tent  or  in  a  small  room,  are  used  to  ad- 
vantage. Steam  will  also  answer  well  under  the  same 
circumstances. 

When  the  diphtheritic  pseudomembrane  is  within  reach, 

177 


DR.    JACOBI'S    WORKS 

it  should  be  either  destroyed  or  disinfected.  For  that  pur- 
pose one  or  two  drops  of  a  fifty-per-cent.  solution  of  car- 
bolic acid  in  glycerin  may  be  applied  once  (not  more  than 
twice)  a  day,  or  of  the  tincture  of  iodine,  or  of  a  solution 
of  1  part  of  the  bichloride  of  mercury  in  100  or  500 
parts  of  water,  several  times  a  day.  It  is  in  these  cases 
that  chlorine  water  has  been  injected  through  the  surface 
into  the  upper  layers  of  the  tonsils.  But  we  should  never 
forget  that  only  a  small  part  of  the  pharynx  is  accessible 
to  such  treatment,  and  that  it  is  only  one  class  of  patients 
that  can  be  subjected  to  it.  In  order  to  be  effective,  the 
application  must  be  thorough.  None  but  adults  or  older 
children,  and  of  them  only  a  small  number,  will  submit 
to  opening  their  mouths  and  to  the  applications.  It  is 
that  very  class  of  patients  who  can  be  induced  to  gargle 
with  some  little,  though  very  little,  success.  Smaller  chil- 
dren will  object,  will  defend  themselves,  will  struggle. 
It  takes  many  an  anxious  moment  to  force  open  the  mouth ; 
meanwhile,  the  patient  is  struggling,  perspiring,  scream- 
ing, and  exhausting  his  strength.  One  may  succeed  in 
forcing  open  the  jaws,  then  there  begins  the  practice  of 
making  applications,  of  swabbing,  of  scratching  off  the 
pseudomembrane,  of  cauterizing,  of  burning.  The  strug- 
gling child  will  prevent  the  limitation  of  the  application 
to  the  diseased  surface.  One  cannot  help  injuring  the 
neighboring  epithelium,  and  thus  the  morbid  process  will 
spread.  Instead  of  doing  good,  we  have  done  harm;  for, 
indeed,  no  local  application  can  do  so  much  good  as  the 
struggles  of  the  frightened  children  do  mischief.  I  have 
seen  them  die  while  defending  themselves  against  the  at- 
tempted violence,  leaving  doctor  and  nurse  victorious  and 
alive  on  the  battlefield.  It  is  incredible,  but  it  is  true, 
that  more  than  one  have  recommended  using  the  electro- 
cautery or  the  thermocautery  on  the  throat  of  the  baby, 
after  forcing  the  mouth  open !  It  is  almost  incredible, 
for  the  offenders  cannot  have  been  ignorant  of  the  fact 
that  what  they  can  reach  with  their  instruments  is  but  very 
little  besides  the  tonsil,  and  they  might  have  known  that 
it  is  just  the  tonsils  that  are  least  apt  to  favor  the  ad- 
mission of  sepsis  into  the  circulation. 

178 


DIPHTHERIA:  SYMPTOMS  AND  TREATMENT 

There  is  an  easy  way  of  using  disinfectants  on  the 
throat  and  mouth,  viz.,  to  give  medicines  which  are  at  the 
same  time  disinfectants,  digestible,  and  easy  to  take ;  to 
give  them  in  small  doses  but  frequently ;  to  see  that  when 
they  have  been  given,  no  water  or  milk  is  taken  imme- 
diately afterwards,  so  as  not  to  wash  them  off  from  the 
mouth  and  throat.  Such  medicines  are  mild  dilutions  of 
the  tincture  of  chloride  of  iron,  or  lime  water,  or  solutions 
of  boric  acid,  or  of  bichloride  of  mercury,  or  of  benzoate 
of  sodium,  most  of  which  will  act  both  by  their  consti- 
tutional and  their  local  effect. 

Diphtheria  is  most  dangerous  when  located  in  the  nose 
and  nasopharynx.  The  changes  taking  place  in  the  nares 
may  be  an  extensive  catarrh,  besides  the  diphtheritic  de- 
posits. The  diphtheritic  membranes  are  sometimes  very 
thick,  and  contain  a  great  deal  of  fibrin.  Sometimes  they 
are  so  thick  as  to  clog  the  nares  and  prevent  respiration. 
Underneath  them  copious  absorption  of  toxins  may  take 
place.  In  most  cases,  however,  the  diphtheritic  membranes 
are  not  so  thick.  Some  of  them  macerate  very  readily, 
and  the  toxin  is  very  speedily  absorbed  through  the  ex- 
ceedingly copious  lymph  ducts,  and  sepsis  is  the  result. 
In  some  cases  of  diphtheria,  however,  the  membranes  can 
hardly  be  seen.  The  discharge  from  the  nose  is  liquid 
and  acrid,  contains  small  flakes  and  some  blood.  These 
are  the  cases  in  which  the  toxin  is  absorbed  directly  into 
the  circulation.  All  of  these  forms  may  lead  to  necrosis 
and  gangrene  of  the  tissue,  and  produce  a  very  peculiar, 
sweetish,  nasty  odor.  Thus,  the  inhaled  air  is  poisoned, 
and,  being  carried  down  into  the  lungs,  acts  as  an  addi- 
tional peril.  The  most  dangerous  locality  is  the  posterior 
nares,  with  their  direct  communications  with  the  lymph 
bodies  below  the  angle  of  the  lower  jaw.  The  pseudo- 
membranes,  the  lymph  ducts,  and  lymph  bodies,  swarm  with 
bacilli  and  toxin,  with  streptococci,  with  staphylococci,  and 
lead  to  immense  tumefaction  between  the  ears  and  clav- 
icles, to  the  formation  of  multiple  small  abscesses,  to  hem- 
orrhages, to  sepsis.  All  of  these  forms  of  nasal  diph- 
theria require  immediate,  persistent,  and  efficient  local 
treatment,  for  it  is  safe  to  say  that  every  case  of  genuine 

179 


DR.    JACOBI'S    WORKS 

or  mixed  nasal  diphtheria  has  a  tendency  to  terminate 
fatally. 

The  local  treatment  consists  in  cleansing  and  disinfect- 
ing. In  most  cases  these  two  are  identical,  for  if  we 
simply  succeed  in  washing  out  the  macerating  material, 
that  proves  sufficient.  In  order,  however,  to  have  that 
effect  the  washing  and  disinfecting  must  be  done  often — 
every  half-hour,  every  hour,  every  two  hours,  day  and 
night.  In  the  bad  cases,  in  which  the  nares  are  clogged 
with  pseudomembrane,  the  cleansing  and  disinfecting  are  to 
be  preceded  by  forcing  a  passage  through  the  nares  with  a 
probe  covered  with  wadding  and  dipped  in  carbolic  acid. 
Particularly  is  this  indication  urgent  when  there  is  sopor, 
which  owes  its  origin  partly  to  the  difficulty  of  respiration 
and  carbonic-acid  poisoning  and  partly  to  the  septic  con- 
dition. The  methods  of  local  treatment,  besides  the  one 
just  described,  are  the  (not  always  successful)  applica- 
tions of  ointments  within  the  nose  by  means  of  the  brush 
or  wadded  probe,  or  the  use  of  the  spray  or  syringe  or 
irrigator,  or  the  use  of  a  spoon  or  a  nasal  cup  or  a  feed- 
ing-cup, through  which  liquids  are  poured  into  the  nares. 
The  indispensability  of  these  nasal  administrations  cannot 
be  urged  too  positively.  Park  thinks  that  "  when  the 
strength  is  good  and  the  nostrils  and  throat  are  full  of 
discharge  and  membrane,  it  is  well  to  insist  on  cleansing 
by  irrigation;  when,  however,  the  child  is  much  prostrated, 
and  struggles  against  it,  irrigation  may  have  to  be  omitted  " 
("  An  American  System  of  the  Practice  of  Medicine,"  i., 
p.  684).  I  believe,  however,  that  in  nasal  diphtheria  local 
treatment  is  the  vital  indication. 

In  making  local  applications  it  is  important  that  the 
whole  surface  should  be  touched;  therefore  neither  oint- 
ments nor  instillations  from  a  medicine-dropper  are  avail- 
able in  the  average  cases  in  which  the  whole  nasopharynx 
is  the  seat  of  the  affection;  nor  as  a  rule  will  the  atomizer 
convey  a  sufficient  amount  of  liquid  into  the  cavities  to 
be  of  much  use.  A  spoon  or  a  small  feeding-cup,  or  better 
one  of  the  nasal  cups  made  for  the  purpose,  the  nozzle  of 
which  is  narrow  enough  to  enter  the  nose,  will  do  fairly 
well,   and  will   allow  the  introduction   of  liquids   into  the 

180 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

nares  in  small  or  large  amounts,  all  of  which  will  enter 
the  throat,  be  either  swallowed  or  flow  out  of  the  other 
nostril  or  out  of  the  mouth.  The  irrigator  (fountain  syr- 
inge) is  liable,  by  undue  pressure,  which  cannot  always  be 
well  measured,  to  injure  the  ear.  It  is  true  that  this  cannot 
take  place  very  readily  so  long  as  the  whole  naso- 
pharynx is  covered  with  pseudomembrane,  but  this  will 
not  always  remain,  and  then  there  is  a  possibility  of 
the  injection,  when  forced  in,  entering  the  middle  ear. 
This  will  take  place  the  more  readily  the  younger  the  in- 
fant, because  the  pharyngeal  orifice  of  the  Eustachian  tube 
is  relatively  larger  and  more  funnel-like  in  the  very  young 
than  in  those  of  more  advanced  age.  On  the  other  hand, 
this  configuration  of  the  Eustachian  tubes  favors  the  es- 
cape of  fluids  from  the  middle  ear;  that  is  why  otitis  media 
in  the  very  young  is  often  painless.  I  generally  prefer 
a  small  glass  syringe  with  a  conical  nozzle  of  soft  rubber. 
It  will  close  up  the  nostril,  the  pressure  can  always  be 
measured  and  modified  (it  should  be  very  gentle),  and  it 
is  effective.  The  injections  must  be  made  with  the  patient 
in  the  recumbent  or  semirecumbent  position.  On  no  con- 
dition, however,  must  a  child  with  diphtheria  be  taken  out 
of  bed  for  the  purpose  of  having  the  nares  washed  and 
disinfected.  I  know  of  many  cases  in  which  the  patient 
died  simply  from  being  repeatedly  taken  up.  The  in- 
jection or  irrigation  is  best  made  by  a  person  who  sits 
on  the  edge  of  the  bed  behind  the  patient,  and  raising  his 
head  gently  supports  it  with  his  chest.  A  towel  should 
quickly  be  thrown  over  the  chest  of  the  patient,  and  an- 
other attendant  should  secure  the  patient's  hands.  All 
preparations  should  be  made  out  of  sight.  Slow  irrigation 
should  always  be  preferred  to  injection  when  there  is  some 
bleeding  after  every  application. 

The  fluids  to  be  used  may  be  quite  simple,  but  should 
always  be  warm.  In  many  cases  a  solution  of  table  salt 
in  water  (7:  1,000),  or  boracic  acid  (2  or  4:  100),  or  lime 
water  will  answer  all  purposes.  The  latter  is  particularly 
indicated  when  there  is  a  thin,  acrid,  slightly  fetid  dis- 
charge. A  more  efficacious  disinfectant  than  all  of  those 
mentioned  is  the  bichloride  of  mercury,  1  part  mixed  with 

181 


DR.    JACOBI'S    WORKS 

10  parts  of  chloride  of  sodium  or  chloride  of  ammonium 
in  from  2^000  to  10,000  parts  of  water.  It  may  be  used 
freely. 

If  moderate  quantities  of  a  mild  solution  of  bichloride 
of  mercury  be  swallowed  while  being  injected,  no  harm  is 
done.  Where  there  is  a  fetid  odor,  the  nares  ought  to 
be  deodorized  frequently  by  carbolic  acid  or  creolin  or 
permanganate  of  potassium. 

Carbolic  acid  may  be  used  in  solutions  of  from  1  to 
10:  1000  parts  of  water,  but  it  should  not  be  forgotten 
that  there  is  some  danger  in  swallowing  it,  because  of  the 
nephritis  to  which  it  may  give  rise.  For  the  same  pur- 
pose of  deodorizing,  creolin  may  be  used  in  one-per-cent. 
solution.  Lceffler's  solution  of  alcohol  60,  toluol  36,  and 
tincture  of  iron  sesquichloride  4  parts,  does  not  act  better 
than  others,  has  a  bad  taste,  is  objected  to  very  strongly, 
and  gives  rise  to  exhausting  struggles.  Permanganate  of 
potassium  in  solution  (1:250)  may  be  applied  once  or 
twice  a  day  to  the  fetid  nares  with  a  probe  wrapped  in 
absorbent  cotton,  or  may  be  used  for  spraying,  for  inj  ection, 
or  for  irrigation  in  a  solution  of  1 :  2,000-4,000  many 
times  a  day.  Peroxide  of  hydrogen  is  a  powerful  disin- 
fectant; some  of  its  eulogizers  condemn  such  preparations 
as  are  acid,  others  those  which  are  not  acid.  Solutions 
which  are  not  very  dilute  will  coagulate  the  soluble  albumin 
of  the  surface  tissue  with  which  they  come  in  contact; 
form  membranous  deposits  which  are  frequently  mistaken 
for  diphtheritic  pseudomembranes ;  giye  rise,  when  the 
membranous  artefacts  will  have  been  thrown  off,  to  local 
sores,  which  may,  and  very  often  do,  furnish  a  resting- 
place  to  new  microbic  invasions.  This  should  be  taken  into 
consideration,  and  is  true,  though  one  of  the  manufacturers 
of  this  substance  once  tried  to  increase  the  vigor  of  the 
advertisement  of  his  wares  by  coupling  with  it  his  convic- 
tion of  my  ignorance  on  the  subject. 

For  the  purpose  of  dissolving  membranes,  papayotin 
(not  the  proprietary  medicine  sold  under  a  similar  name) 
has  been  used  in  five-per-cent.  solutions,  as  a  spray,  by 
injection,  or  as  a  direct  application  by  means  of  a  sponge 
or  brush.     Many  years  ago  I  employed  it  in  greater  con- 

182 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

centration  to  dissolve  the  diphtheritic  membranes  of  the 
trachea  below  the  tracheotomy  tube.  Its  application  in 
powder  does  not  answer  well.  For  the  same  purpose  tryp- 
sin has  been  employed  in  five-per-cent.  solutions,  mixed 
with   bicarbonate   of   sodium. 

The  cervical  lymphadenitis,  of  which  I  have  spoken  as 
the  result  of  nasal  diphtheria,  must  be  treated  persist- 
ently and  effectively.  This  treatment  may  be  preventive 
and  curative.  The  preventive  treatment  consists  in  the 
nasal  injections  described.  The  rapidity  with  which  large 
swellings  diminish  when  irrigations  are  made  frequently 
and  conscientiously  is  often  surprising.  When  large  tume- 
faction has  taken  place,  tincture  of  iodine  has  been  ap- 
plied externally;  in  that  way  it  is  useless.  Mercurial  oint- 
ments and  oleates  have  been  applied ;  they  also  are  useless, 
either  as  actual  remedies  or  as  a  means  of  massage.  An 
ointment  of  potassic  iodide  and  adeps  lanae  hydrosus 
(1:6-8)  is  more  readily  absorbed  and  less  irritating.  Ice 
externally  is  rational,  but  it  is  useless  so  long  as  the 
infection  is  not  stopped.  I  have  in  a  number  of  instances 
injected  iodoform,  in  ether,  into  the  swelled  mass,  but  it 
is  too  painful  and  too  efficacious,  and  does  not  pay  for  the 
agitation,  anguish,  and  exhaustion  of  the  unfortunate  child. 
So,  indeed,  there  is  no  remedy,  besides  the  preventive 
measures,  except  in  occasional  long  and  deep  incisions  into 
the  immense  mass.  We  §hould  not  wait  for  fluctuation 
or  even  semi-fluctuation  to  become  apparent.  A  great  deal 
of  the  swelling  is  inside  the  fascia.  Abscesses,  when  they 
form,  are  seldom  large.  The  contents  consist  more  of 
necrotic  tissue,  which  ought  to  be  laid  open  as  soon  as 
possible  and  disinfected.  The  incision  must  be  a  long 
one- — in  many  cases  from  ear  to  clavicle.  The  disinfection 
of  the  wound  may  be  obtained  by  applications  of  subnitrate 
of  bismuth  or  tincture  of  iodine,  and  by  iodoform  or 
other  antiseptic  gauze.  No  carbolic  acid  should  be  used 
for  disinfection,  because  of  its  tendency  to  give  rise  to 
hemorrhages.  When  a  hemorrhage  takes  place,  it  will 
usually  stop  under  pressure  with  antiseptic  gauze;  but 
sometimes,  when  a  large  blood-vessel  has  been  eroded,  it 
is  very   copious.      In   such   cases   the   actual  cautery,  acu- 

183 


DR.    JACOBI'S    WORKS 

pressure,  or  sometimes  the  ligature  of  blood-vessels  has  to 
be  resorted  to.  Chloride  of  iron  and  subsulphate  of  iron 
must  never  be  used  on  such  necrotic  surfaces.  They  give 
rise  to  a  thick  coagulated  scab  under  which  septic  absorp- 
tion is  apt  to  take  place. 

Sanguinolent  discharges  from  the  nostrils  may  usually 
be  arrested  by  the  conscientious  application  of  cleansing 
and  disinfecting  solutions  (in  most  cases  gentle  irrigation 
works  best).  But  the  subsulphate  or  perchloride  of  iron 
should  generally  not  be  employed  for  the  reason  above 
given.  The  application  of  a  solution  of  antipyrin  (1:  10, 
sometimes  1:3)  by  means  of  a  swab  or  a  spray  will  gen- 
erally prove  satisfactory  in  hemorrhages.  In  urgent  cases 
a  tampon  saturated  in  a  solution  of  antipyrin  is  required; 
its  styptic  property  is  enhanced  by  the  addition  of  a  small 
amount  of  tannic  acid. 

Moderate  hemorrhages  from  the  throat  should  be  treated 
in  a  similar  way,  and  by  ice-bags  properly  applied.  Un- 
less they  be  parenchymatous  their  locality  should  be  in- 
quired into  for  the  purpose  of  the  localization  of  a  styptic 
— antipyrin,  or  the  actual  cautery.  If  there  be  an  erosion 
of  a  large  vessel,  such  as  the  carotid  artery  in  a  case 
reported  by  me  in  the  Transactions  of  the  Association  of 
American  Physicians  (1898),  nothing  short  of  the  ligation 
of  the  vessel  is  appropriate.  If  it  be  the  jugular  vein 
which  is  ruptured,  either  ligation  or  compression  should 
be  resorted  to. 

Local  treatment  has  lost  its  credit  with  some  who  be- 
lieve that  antitoxin  alone  should  be  relied  on  in  all  cases, 
and  for  all  indications.  That  is  a  grave  mistake,  which 
will  again  be  referred  to  below. 

For  the  purpose  of  softening  and  macerating  pseudo- 
membranes  steam  has  been  extensively  utilized.  Its  in- 
halation is  useful  in  cases  of  catarrh  of  the  mucous  mem- 
branes, and  in  many  inflammatory  and  diphtheritic  affec- 
tions. On  mucous  membranes  it  will  increase  the  secretion 
and  liquefy  it,  and  thus  aid  in  the  throwing  off  of  the 
pseudomembranes.  Its  action  is  the  more  pronounced  the 
greater  the  amount  of  muciparous  follicles  under  or  along- 
side  a   cylindrical    or    fimbriated   epithelium.      Thus    it    is 

184 


DIPHTHERIA:    SYMPTOMS     AND     TREATMENT 

that  tracheobronchial  diphtheria  and  the  non-bacillary 
forms  of  fibrinous  bronchitis  are  greatly  benefited  by  it. 
Children  affected  with  them  I  have  kept  in  small  bath- 
rooms for  days,  turning  on  the  hot  water,  and  obliging 
the  patient  constanth'  to  breathe  the  hot  vapor.  In  several 
such  cases  I  have  seen  recovery  with  that  treatment. 
Atomized  cold  water  will  never  yield  the  same  result; 
nor  have  I  seen  the  patented  inhalers  do  much  good. 
Still,  where  the  surface  epithelium  is  pavement  rather  than 
cylindrical,  and  where  but  few  muciparous  follicles  are 
present,  and  when  the  pseudomembrane  is  rather  immerged 
in,  and  firmly  coherent  with,  the  surface — for  instance., 
on  the  tonsils — the  steam  treatment  is  less  appropriate. 
On  the  contrary,  moist  heat  is  liable  in  such  cases  to  favor 
the  extension  of  the  process  by  softening  the  hitherto 
healthy  mucous  membrane.  Thus  it  takes  all  the  tact  of 
the  practitioner  to  select  the  proper  cases  for  the  admin- 
istration of  steam,  not  to  speak  of  the  judgment  which  is 
required  to  determine  to  what  extent  the  exclusion  of  air 
(oxygen)  from  the  steam-moistened  room  or  tent  is  per- 
missible. 

Steam  may  be  properly  mixed  with  medicinal  vapors. 
In  the  room  of  the  patient  water  is  kept  constantly  boiling 
over  the  fireplace,  provided  the  steam  is  prevented  from 
escaping  directly  into  the  chimney,  on  a  stove  (the  modern 
"  self-feeders  "  are  insufficient  for  that  purpose  and  are 
abominations  for  every  reason),  over  an  alcohol  lamp,  if 
we  cannot  do  better,  but  not  on  gas,  if  possible  to  avoid 
it,  because  of  the  large  amount  of  oxygen  which  it  con- 
sumes. Every  hour  a  tablespoonful  of  oil  of  turpentine, 
or  of  eucalj'ptus,  and  perhaps  also  a  teaspoonful  of  carbolic 
acid,  is  poured  on  the  water  and  evaporated  with  it.  The 
air  of  the  room  is  filled  with  steam  and  vapors,  and  thus  the 
contact  with  the  sore  surfaces  and  the  respiratory  tract 
is  obtained  with  absolute  certainty. 

The  secretion  of  the  mucous  membranes  is  sometimes 
quite  abundant  under  the  influence  of  steam,  but  is  still 
more,  like  that  of  the  external  integuments,  increased  by 
the  introduction  of  water  into  the  circulation.  Therefore, 
drinking  of  large  quantities  of  water   or  of  water  mixed 

185 


DR.    JACOBI'S    WORKS 

with  alcoholic  stimulants  should  be  encouraged.  Over  a 
thoroughly  moistened  mucous  membrane  the  pseudomem- 
brane  is  more  easily  made  to  float  and  to  macerate. 

To  evolve  large  volumes  of  steam  the  slaking  of  lime 
has  been  resorted  to.  It  is  both  an  old  and  an  effective 
procedure.  Not  only  is  the  object  in  view  accomplished 
by  it,  but  it  is  the  best  means  of  bringing  lime  into  con- 
tact with  the  morbid  surface.  In  a  room  in  which  lime 
has  been  slaked,  everything  is  covered  with  it.  Thus  this 
method  of  profiting  by  the  local  effect  of  lime  is  decidedly 
preferable  to  the  almost  nugatory  effect  of  lime  water 
spraj^ed  into  the  throat. 

In  connection  with  these  measures,  taken  for  influencing 
the  mucous  secretions  and  exudations  of  the  mucous  mem- 
branes, I  may  here  refer  to  some  internal  medication  re- 
sorted to  with  the  same  object  in  view.  It  was  to  fulfil 
the  same  indication  of  softening  the  pseudomembrane,  by 
increasing  the  secretion  of  the  mucous  membranes,  that 
pilocarpine  or  jaborandi  was  highly  recommended  (Gutt- 
mann)  as  a  panacea  in  all  forms  of  diphtheria.  There 
is  no  doubt  that  the  secretion  of  the  mucous  membranes 
is  vastly  increased  by  the  internal  administration,  or  by 
repeated  subcutaneous  injections  of  the  muriate  or  nitrate 
of  pilocarpine,  but  the  heart  is  enfeebled  by  its  use.  I 
have  seen  but  few  cases  in  which  I  could  continue  the 
treatment  for  a  sufficient  time.  In  many  I  had  to  stop  it 
because  after  some  days  of  persistent  administration  I 
feared  for  the  safety  of  the  patients.  Therefore,  as  early 
as  1880,  at  the  meeting  in  that  year  of  the  American  Med- 
ical Association  at  Richmond,  I  felt  obliged  to  warn 
against  its  indiscriminate  use  in  diphtheria.  Thus  it  has 
shared  the  fate  of  all  the  hundreds  of  remedies  and  meth- 
ods which  have  been  declared  to  be  infallible  and  have 
been   found  wanting. 

The  diphtheritic  conjunctiva  should  be  irrigated  fre- 
quently, every  half-hour  or  every  hour,  with  a  mild  anti- 
septic solution  (boracic  acid  1-4:  100).  These  irrigations 
are  quite  often  difficult  to  make  because  of  the  massive 
infiltration  of  the  tissues.  To  counteract  this  and  its  pres- 
sure on  the  eyeball,  I  saw,  thirty  years  ago,  a  deep  hori- 

186 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

zontal  incision  made  through  the  external  angle.  In  some 
cases  the  pressure  was  relieved  in  spite  of  the  extension 
of  the  diphtheria  along  the  wound.  Ice  applications  to 
the  eye  are  always  indicated,  particularly  at  first.  If  bags 
will  not  be  tolerated,  cloths  large  enough  to  cover  the 
eye  should  be  placed  on  a  lump  of  ice  and  applied  fresh, 
without  previous  wringing,  every  two  minutes.  These  ice 
applications  should,  however,  be  watched.  They  are  liable 
to  increase  the  anaemia  caused  by  the  infiltration  of  the 
tissues  and  give  rise  to  necrosis.  Such  occurrences  should 
be  met  by  warm  applications,  which  may  increase  the 
tendency  to  maceration.  Abscesses  in  the  lower  part  of 
the  cornea  should  not  be  opened.  Accompanying  eczema 
or  erythema  of  the  cheeks  should  be  treated  with  an 
iodoform-vaseline  ointment  (1:6-10),  and  cellulitis  of  the 
surrounding  tissue  of  the  cheek  according  to  the  common 
principles   of  antiseptic  surgery. 

Ammann  treated  six  serious  cases  of  diphtheria  of  the 
eye  with  repeated  injections  of  antitoxin,  which  were  not 
successful.  It  appears  its  effect  is  doubtful  when  the 
cornea  is  affected,  and  mainly,  as  it  happened  in  his  cases, 
when  diphtheritic  conjunctivitis  and  keratitis  were  com- 
plicated with  the  presence  of  cocci. 

GENERAL     TREATMENT 

The  dietetic  treatment  of  a  case  of  diphtheria,  either 
simple  and  uncomplicated,  or  mixed,  or  septic,  should  be 
guided  by  circumstances  and  general  principles.  Solid 
food  is  rarely  relished  and  generally  refused,  though  there 
be  but  little  pain  in  swallowing.  A  child  may  be  per- 
mitted to  go  without  food  for  the  first  day  or  longer.  But 
the  tendency  to  leucocytosis,  hydraemia,  and  toxic  exhaus- 
tion demands  measures  for  the  preservation  and  restora- 
tion of  strength.  Milk  in  different  forms,  with  and  without 
farinaceous  admixtures,  broths  and  beef  juice,  eggs  in 
acceptable  form,  and  alcoholic  stimulants  at  an  earl}"^  time 
should  be  insisted  upon.  It  should  be  superfluous  to  urge 
the  necessity,  while  trying  to  remove  the  disease,  of  pre- 
serving the  patient. 

187 


DR.    JACOBI'S    WORKS 

The  medical  treatment  of  an  average  case  of  pharyngeal 
diphtheria  can  be  made  to  combine  the  indications  of  both 
internal  and  local  administration.  For  forty  years  I  have 
employed  the  tincture  of  the  chloride  of  iron.  It  is  an 
astringent  and  antiseptic.  Its  contact  with  the  diseased 
surface  is  as  important  as  is  its  general  effect;  therefore 
it  should  be  given  frequently,  in  hourly  or  half-hourly 
doses,  even  every  twenty  or  fifteen  minutes.  An  infant 
of  a  year  may  take  3  or  4  c.c.  (o  i.)  a  day,  a  child  of  three 
or  five  years  8  or  12  c.c.  (3  ij.  or  iij.).  It  is  mixed  with 
water  so  as  to  make  the  dose  half  a  teaspoonful  or  a  tea- 
spoonful;  a  drachm  or  two  drachms  (4  or  8  c.c.)  with  a 
small  quantity  of  chlorate  of  potassium  (see  above),  in 
four  ounces  (120  c.c.)  allows  half  a  teaspoonful  every 
twenty  minutes.  No  water  must  be  drunk  after  the  medi- 
cine. As  a  rule,  it  is  well  tolerated.  There  are  some, 
however,  who  will  not  bear  it  well.  Vomiting  or  diarrhoea 
is  a  contraindication  to  perseverance  in  its  use,  for  noth- 
ing must  be  allowed  to  occur  which  reduces  strength.  A 
good  adjuvant  is  glycerin,  and  better  than  syrups.  From 
ten  to  fifteen  per  cent,  of  the  mixture  may  consist  of  it. 
Now  and  then,  but  rarely,  it  is  not  at  all  tolerated.  When 
diarrhoea  sets  in  glycerin  should  be  discontinued.  Still, 
these  cases  are  rare;  indeed,  the  stomach  bears  glycerin 
very  much  better  than  the  rectum. 

I  have  seen  so  many  bad  cases  recover  under  the  ad- 
ministration of  chloride  of  iron,  when  treated  after  the 
method  detailed  above,  that  I  cannot  rescind  former  ex- 
pressions of  my  belief  in  its  value.  Still,  I  have  often 
been  so  situated  that  I  had  to  give  it  up  in  peculiar 
cases.  They  were  those  in  which  the  main  symptoms  were 
of  so  intense  a  sepsis  that  the  iron  and  other  rational 
methods  of  treatment  were  not  powerful  enough  to  pre- 
vent the  rapid  progress  of  the  disease.  Children  with 
nasopharyngeal  diphtheria,  large  glandular  swelling,  feeble 
heart,  and  frequent  pulse,  thorough  sepsis,  and  irritable 
stomach  besides,  those  in  whom  large  doses  only  of  stimu- 
lants, general  and  cardiac,  may  possibly  bring  any  relief, 
are  better  off  without  the  iron.  When  the  circumstances 
are  such  as  to  leave  the  choice  between  iron  and  alcohol, 

188 


DIPHTHERIA:     SYMPTOMS    AND     TREATMENT 

it  is  best  to  omit  the  iron  and  rely  on  alcoholic  stimulants 
mostly.  The  quantities  required  are  so  large  that  the 
absorbent  powers  of  the  digestive  tract  are  no  longer  suf- 
ficient for  both. 

Nor  is  iron  sufficient  or  safe  in  those  cases  which  arc 
pre-eminently  laryngeal.  To  rely  on  iron  in  membranous 
croup  means  both  waste  and  danger. 

When  pharyngeal  diphtheria  has  reached  the  larynx  in 
its  descent,  or  when  bronchial  diphtheria  in  its  ascent 
has  resulted  in  sudden  laryngeal  stenosis,  the  above  anti- 
diphtheritic  treatment  avails  but  little.  That  neither  gen- 
eral nor  local  depletion  has  any  effect,  except  that  of 
hopelessly  reducing  the  patient's  strength,  has  long  been 
recognized;  also  that  vesicatories  add  new  diphtheritic 
exudations  on  the  denuded  surfaces  to  those  already  on 
the  mucous  membranes.  Emetics  are  of  no  use  unless  a 
peculiar  flapping  sound  betra3'S  the  presence  of  half-de- 
tached membrane  in  the  air  passage.  In  such  a  case 
they  are  apt  to  save  life.  Massage  of  the  larynx  has 
been  recommended  by  Bela  Weiss.  I  cannot  say  that 
the  few  cases  in  which  I  advised  the  procedure  were 
successful;  it  may  be  that  the  constant  repetition  of  the 
advice  to  use  mercurial  or  other  ointments  over  the  larynx 
is  based  on  the  observation  of  an  occasional  good  effect 
of  the  friction  ("  massage  ")  attending  their  employment. 
Locally,  lactic  acid,  in  more  or  less  saturated  solution, 
has  been  eulogized  as  a  solvent  of  the  membranes  in  the 
larynx,  when  often  applied  either  by  brush  or  spray.  Most 
of  the  cases  in  which  I  have  seen  it  used  were  not  suc- 
cessful ;  but  an  untoward  result  in  these  cases  is,  unfor- 
tunately, not  exceptional.  I  have  seen,  or  believe  I  have 
seen,  papayotin  dissolve  membrane  when  applied  in  a  mix- 
ture of  one  part  in  two  parts  each  of  glycerin  and  water. 
Particularly  would  that  occur  in  pharyngeal  diphtheria 
slowly  descending.  Lime  water  is  still  used  as  a  spray 
and  has  its  admirers.  Lime  slaked  in  a  small  room,  or 
under  a  tent,  is  decidedly  more  effective,  for  during  that 
process  a  large  quantity  of  lime  is  carried  up  and  inhaled; 
at  the  same  time  the  softening  and  solvent  effect  of  the 
steam  is  obtained,  but  the  latter  is  not  always  so  benefi- 

189 


JACOBI'S    WORKS 

cent  as  it  appears.  In  many  the  application  externally 
of  cold  water  or  ice-bags  to  the  neck  is  vastly  preferable. 
But  in  most  cases  of  anaemic  and  highly  nervous  children 
the  latter  are  not  tolerated.  Constant  inhalations  of  tur- 
pentine or  carbolic  acid  from  a  kettle  of  boiling  water 
have  impressed  me  as  beneficial  in  a  large  number  of  cases. 
Inhalations,  in  a  small  room  or  under  a  tent,  of  calomel, 
which  is  sublimated  in  doses  of  gr.  viij.  or  x.  (0.5  gm.), 
every  hour  or  at  longer  intervals,  are  certainly  effective. 

The  patient  remains  in  bed  as  much  as  possible,  and 
may  continue  such  expectorants  as  he  perhaps  took  for 
previous  catarrhal  symptoms;  he  may  also  take  diaphoretics 
and  warm  beverages;  an  occasional  opiate  to  excite  dia- 
phoresis and  to  procure  some  rest.  The  continued  use  of 
chlorate  of  potassium,  when  the  invasion  of  the  larynx 
is  complete,  is  rather  superfluous.  Antipyretics  are  out  of 
the  question  unless  there  is  a  very  high  temperature  de- 
pending on  a  complication  (general  diphtheria,  pulmonary 
inflammations).  Pilocarpine  injures  by  debilitating  the 
patient;  the  cases  which  are  really  benefited  by  it  are 
exceedingly  rare.  Mercurials  have  resulted  in  more  actual 
recoveries  than  has  any  other  internal  treatment.  The 
cyanide  and  iodide  have  been  recommended.  For  nearly 
twenty  years  I  have  employed  the  bichloride  in  doses  of 
1  mgm.  (gr.  %o)  OJ*  niore  once  every  hour.  The  smallest 
babies  take  one- fourth  or  one-third  of  a  grain  daily  for 
days  in  succession.  Almost  never  will  a  stomatitis  follow, 
and  no  gastric  or  intestinal  irritation,  provided  the  di- 
lution be  in  the  proportion  of  at  least  1 :  8000.  An  oc- 
casional slight  diarrhoea  may  require  the  addition  of  a 
few  drops  of  camphorated  tincture  of  opium,  I  can 
repeat  a  former  statement,  that  never  before  the  antitoxin 
period  (see  below)  have  I  seen  cases  of  croup  getting  well 
in  such  numbers,  either  without  or  with  tracheotomy  or 
intubation,  as  when  under  mercurial  treatment.  I  would 
not  be  understood,  however,  to  limit  the  use  of  mercury 
to  laryngeal  diphtheria;  it  has  equal  effects  in  that  of 
the  pharynx,  and  mostly  in  the  streptococcic  and  in  the 
mixed  forms  of  diphtheria.  In  connection  with  this  state- 
ment I  wish  to  emphasize  again  the  necessity  of  not  relying 

190 


DIPHTHERIA:  SYMPTOMS  AND  TREATMENT 

on  a  single  method  of  treatment  in  a  disease  so  dangerous 
and  whimsical  as  diphtheria.  The  self-complacent  nihilism 
which  relies  exclusively  on  pathological  research  and 
laboratory  methods  has  more  than  once  impeded  the  medi- 
cal and  social  and  humanitarian  position  of  clinical  medi- 
cine. It  is  a  pleasure,  therefore,  to  quote  an  author  who 
has  won  laurels  in  bacteriology:  "  The  giving  internally 
of  the  tincture  of  the  chloride  of  iron  or  of  the  bichloride 
of  mercury  in  small  frequent  doses  has  considerable  local 
effect  upon  the  mucous  membranes  of  the  throat  and 
pharynx  "    (W.  H.  Park). 

When,  in  laryngeal  diphtheria,  internal  treatment  proves 
unsuccessful,  intubation  or  tracheotomy  should  be  resorted 
to.  A  small,  frequent,  and  intermittent  pulse,  aphonia, 
cyanosis,  and  marked  retraction,  with  every  inspiration,  of 
the  supraclavicular  fossae  and  the  epigastrium,  are  most 
urgent  indications  for  the  operative  procedure.  They 
should  not  be  allowed  to  last.  I  shall  not  here  be  tempted 
to  discuss  the  criminality  of  allowing  a  child  to  suffocate 
without  resorting  to  mechanical  relief,  or  to  compare  the 
two  operations  with  each  other.  I  can  only  say  that  for 
years  I  have  not  seen  a  case  in  which  intubation  would 
not  take  the  place  of  tracheotomy,  and  have,  therefore, 
not  performed  the  latter.  Intubation  takes  the  place  of 
tracheotomy  in  most  cases;  in  none  does  it  make  it  im- 
possible when  required  in  the  opinion  of  the  operator. 
The  latter  operation  may  be  preferred  or  become  neces- 
sary for  the  purpose  of  getting  at  the  trachea  and  bronchi 
for  the  mechanical  removal  of  membrane  and  other  local 
treatment,  rare  though  the  cases  be  in  which  such  pro- 
cedures are  attended  with  success.  It  is  probable  that  the 
many  secondary  tracheotomies  which  are  still  performed  in 
Europe  when  intubation  is  alleged  to  be  insufficient  will 
not  be  considered  requisite  in  the  future.  Nor  is  it  prob- 
able that  Bokai's  method  of  using  intubation  as  an  ad- 
juvant to  tracheotomy  will  be  followed  long  even  by  that 
distinguished  clinician  himself.  Since  1891  his  practice 
has  been  first  to  perform  intubation  and  then  tracheotomy, 
removing  the  tube  just  before  he  makes  his  incision  into 
the  trachea. 


DR.    JACOBI'S    WORKS 

In  the  vast  majority  of  cases  of  pseudomembranous 
laryngitis  the  Klebs-Loeffler  bacillus  is  found;  and  all  of 
them  are,  therefore,  fit  subjects  for  the  use  of  the  diph- 
theria antitoxin.  Since  its  introduction  both  general  and 
local  (laryngeal)  diphtheria  have  been  greatly  benefited. 
At  its  Washington  meeting  in  May,  1897,  the  American 
Pediatric  Society  received  the  "  Report  of  its  committee 
on  the  collective  investigation  of  the  antitoxin  treatment 
of  laryngeal  diphtheria  in  private  practice."  Its  salient 
points  are  as  follows:  The  number  of  cases  reported  dur- 
ing the  eleven  months  ending  April  1st,  1897,  was  1704 
• — mortality,  21.12  per  cent.  The  cases  occurred  in  the 
practice  of  422  physicians  in  the  United  States  and  Can- 
ada. Operations  employed:  Intubation  in  637  cases,  mor- 
tality 26  per  cent. ;  tracheotomy  in  20  cases,  mortality  45 
per  cent. ;  intubation  and  tracheotomy  in  1 1  cases,  mor- 
tality 63.63  per  cent.  Number  of  States  represented,  22, 
besides  the  District  of  Columbia  and  Canada.  Non-op- 
erative cases,  1036,  mortality  17.18  per  cent.;  operated 
cases,  668,  mortality  27.24  per  cent. 

Two  facts  may  be  recalled  in  connection  with  these 
statements:  First,  that  before  the  use  of  antitoxin  90 
per  cent,  of  cases  of  laryngeal  diphtheria  required  opera- 
tion; under  the  antitoxin,  however,  39-21  per  cent.  Second, 
that  the  percentage  figures  have  been  reversed:  formerly 
27  per  cent,  represented  the  recoveries ;  now,  under  anti- 
toxin, this  figure  represents  the  ndortality.  The  committee 
expects  still  better  results  when  antitoxin  will  be  admin- 
istered earlier  and  in  larger  doses,  and  recommends  that 
all  patients  with  laryngeal  diphtheria,  being  two  years  or 
over,  should  receive  as  follows:  Two  thousand  units  at 
the  earliest  possible  moment,  two  thousand  units  after 
twelve  or  eighteen  hours,  unless  there  be  an  improvement, 
and  the  same  dose  twenty-four  hours  after  the  second 
dose,  if  there  be  still  no  improvement.  Patients  under  two 
years  should  receive  one  thousand  or  fifteen  hundred  units. 

Dr.  Dillon  Brown's  personal  experience  being  unusualh' 
large  and  carefully  recorded.  I  add  without  comment  the 
following  figures  reported  by  him.  He  divided  his  intu- 
bation   cases    into    three    clases:      Previous    to    November, 

192 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

1890;  from  November,  1890,  to  September,  1894  (calo- 
mel sublimation  period);  from  September,  1894,  to  April 
1st,  1897  (antitoxin  period).  Of  442  cases  of  intubation 
without  calomel  sublimations  and  without  antitoxin,  27-3  per 
cent,  recovered.  Of  295  cases  of  intubation  with  calomel 
sublimations,  41.6  per  cent.;  of  69  cases  of  intubation 
with  antitoxin,  67.8  per  cent,  recovered.  Without  subli- 
mations, 10.1  per  cent.;  with  sublimations,  13.2  per  cent.; 
with  antitoxin,  23.3  per  cent,  recovered.  During  the  first 
year  with  antitoxin,  there  were  recoveries  after  operation 
in  38.4;  during  the  second  year  in  62.9;  during  the  third 
in  94.7  per  cent.  The  apparently  bad  results  during  the 
first  year  were  probably  due  to  two  causes:  inferior  an- 
titoxic serums   and  insufficient  doses. 

Caille  sums  up  his  personal  experience  as  follows: 
"  Tracheotomy  and  intubation  cases,  before  antitoxin,  280 
cases,  30  per  cent,  recovered;  17  intubation  cases,  with 
antitoxin,  3  deaths.  Over  one-half  of  all  laryngeal  cases 
treated  with  antitoxin  recovered  without  operation.  In 
every  case  of  acute  progressive  stenosis  1500  to  2000 
units  of  diphtheria  antitoxin  should  be  administered  at 
once,  and  the  dose  may  be  repeated  in  twelve  to  twenty- 
four  hours,  and  so  on  until  relief  is  manifest." 

In  Baginsky's  hospital  service  there  were  1258  cases 
of  diphtheria  in  the  years  1890-94;  418  tracheotomies  and 
135  intubations  were  performed,  with  a  total  mortality  in 
these  533  operations  of  62  per  cent.  In  the  418  trache- 
otomies the  mortality  was  64.4  per  cent. ;  among  these 
were  77  which  were  performed  after  intubation;  these  77 
had  a  mortality  of  69  per  cent.;  58  intubations  without 
secondary  tracheotomy  had  a  mortality  of  41.8  per  cent. 
This  condition  of  things  changed  with  the  inauguration  of 
antitoxin  treatment.  No  case  of  laryngeal  stenosis  de- 
veloped in  those  in  whom  the  remedy  was  injected  before 
the  larynx  became  affected.  Thus  it  was  that  in  525  cases 
there  were  but  53  tracheotomies  and  54  intubations,  the 
former  with  34  deaths,  the  latter  with  2.  It  became  neces- 
sary to  perform  tracheotomy  after  a  previous  intubation 
in  12  cases,  of  which  9  ended  in  death.  The  speedier 
disintegration  of  the  membranes   and  the   almost  general 

193 


DR.    JACOBI'S    WORKS 

discontinuance  of  their  growth  after  the  injection  of  an- 
titoxin are  the  reasons  why  Baginsky  has  since  preferred 
intubation  to  tracheotomy. 

At  that  early  time  in  which  his  results  were  published, 
Heubner  performed  33  operations  in  181  cases — viz.,  23 
tracheotomies  with  52  per  cent.,  10  intubations  with  80 
per  cent,  recoveries — a  remarkable  improvement  over  the 
figures   of  the  ante-antitoxin   period. 

At  the  International  Congress  of  Moscow  Monti  made 
the  statement  that  in  his  service  cases  of  laryngeal  stenosis 
were  apt  to  get  well  under  the  sole  influence  of  antitoxin, 
that  an  operation  was  resorted  to  only  when  that  treat- 
ment proved  unsuccessful  (after  some  days),  and  even 
then  was  likeh'  to  be  successful.  Without  antitoxin,  in 
former  times,  his  intubations  would  yield  a  mortality  of 
from  25  to  40  per  cent.,  now  while  antitoxin  was  employed, 
12  per  cent.  Only  in  the  "  mixed  "  infections  the  mor- 
tality rose  to  33  per  cent. 

It  is  useless  to  quote  any  more  experiences  in  regard 
to  the  efficacy  of  antitoxin  in  diphtheritic  stenosis  of  the 
larynx.  In  many  cases  it  renders  operations  unnecessary; 
in  those  operated  upon  the  prognosis  is  improved.  Still 
many  die;  of  those  following  "mixed"  infections  many 
die.  If  there  be  those  who  shoulder  the  responsibility  of 
relying  on  a  sole  remedy,  which  frequently  heals  and 
frequently  fails,  to  the  exclusion  of  every  other  helpful 
medication  or  contrivance,  they  are  as  short-sighted  as 
those  who  still  refuse  altogether  to  acknowledge  the  great 
efficacy  of  antitoxin  in  diphtheria.  The  fanaticism  of 
the  one  should  not  be  permitted  to  justify  that  of  the 
other.  The  satisfaction  at  having  a  powerful  remedy  like 
antitoxin  should  not  engender  the  nihilism  which  begins 
after  the  subcutaneous  injection  of  serum.  This  cannot 
be  said  too  often,  particularly  in  reference  to  "  mixed " 
infections.  It  is  only  the  bacillus  part  of  the  malady  which 
can  be  counteracted  by  antitoxin.  The  mixed  infections  at 
least,  with  their  virulence  and  danger,  should  not  be  left 
to  die  without  medication  beyond  injection  and  "  expect- 
ant "  neglect. 

Heart    failure    is    usually    developed    gradually.      It   is 

194 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

foreshadowed  by  an  increasing  frequency  and  weakness  of 
both  heart  beats  and  pulse,  by  an  occasional  intermission, 
by  unequal  frequency  of  the  beats  in  a  given  period  (say 
of  ten  seconds),  or  by  the  equalization  of  the  interval  be- 
tween systole  and  diastole,  and  diastole  and  systole.  This 
latter  condition,  Avhich  is  normal  in  the  embryo  and  foetus, 
is  always  an  ominous  symptom;  so  is  the  too  close  proximity 
of  the  second  sound  (so  as  to  become  almost  inaudible) 
to  the  first. 

Heart  failure  is  due,  besides  the  influences  common  to 
every  disease  and  every  fever,  to  tissue  changes  in  the 
myocardium,  in  its  nerves,  in  the  endocardium,  and  to  the 
gradual  formation  of  blood  clots.  These  changes  may  be 
due  to  the  malnutrition  of  the  tissues  resulting  from 
every  septic  condition  of  the  blood,  or  to  specific  altera- 
tions due  to  the  diphtheritic  process.  Failure  may  come 
on  after  having  given  %varning,  or  it  may  be  on  us  without 
any.  Thus  every  case  of  diphtheria  ought  to  make  us 
anxious  and  afraid.  Indeed,  there  is  no  safety  and  no 
positively  favorable  prognosis  until  the  patient  is  quite 
recovered,  and  even  advanced  beyond  the  period  in  which 
paralysis  may  develop. 

Whatever  enfeebles  must  be  avoided;  absolute  rest  must 
be  enjoined.  The  patients  must  be  in  bed,  without  ex- 
citement of  any  kind;  they  must  take  their  medicines — 
which  ought  to  be  as  palatable  as  possible — and  their 
liquid  food,  and  evacuate  their  bowels  in  a  recumbent  or 
semirecumbent  position;  crying  and  worrying  must  be  pre- 
vented ;  the  room  must  be  kept  airy  and  rather  dark,  so 
as  to  encourage  sleep  if  the  patients  be  restless;  and  rest- 
less they  are,  unless  they  be  under  the  influence  of  sepsis, 
and  thereby  subject  to  fatal  drowsiness  and  sopor.  In  no 
disease,  except  perhaps  in  pneumonia,  have  I  seen  more 
fatal  results  from  exertion  on  the  part  of  the  sick,  or  from 
anything  more  fatiguing  than  a  sudden  change  of  posture. 
Unless  absolute  rest  be  enforced,  neither  physicians  nor 
nurses  have  done  their  duty.  The  latter  must  avoid  all 
the  dangers  attending  the  administration  of  medicines,  in- 
jections, sprays,  and  washes.  Preparations  for  the  same 
must  be  made  out   of  sight,  every   application   should   be 

195 


DR.    JACOBI'S    WORKS 

made  quickly  and  gently.  On  no  account  must  a  patient 
be  taken  out  of  bed  for  any  of  these  purposes.  I  know 
of  children  dying  between  the  knees  of  nurses  who  called 
themselves  trained  and  had  a  diploma. 

The  use  of  pharmaceutical  preparations,  such  as  digitalis, 
strophanthus,  sparteine,  caffeine,  besides  camphor,  alcohol, 
and  musk,  should  not  be  postponed  until  feebleness  and 
collapse  have  set  in.  These  are  at  least  possible,  even 
probable,  and  it  is  certain  that  a  cardiac  stimulant  will  do 
no  harm.  It  is  advisable  to  use  it  at  an  early  date,  par- 
ticularly in  those  cases  in  which  perhaps  antipyrin  or 
antifebrin  (the  indications  for  which  are  certainly  rare, 
as  excessive  temperatures  are  very  exceptional)  is  given. 
Besides,  it  is  not  enough  that  the  patients  should  merely 
escape  death;  they  ought  to  get  up,  cito,  tuto,  et  jucunde, 
with  little  loss  and  speedy  recuperation ;  a  few  grains  of 
digitalis  or  their  equivalent — preferably  a  good  fluid  ex- 
tract— may  or  should  be  given,  in  a  pleasant  and  digestible 
form,  daily.  When  a  speedy  effect  is  required,  one  or  two 
doses  of  two  to  four  minims  each  are  not  too  large,  and 
must  be  followed  up  by  smaller  ones.  When  it  is  justly 
feared  lest  the  effect  of  digitalis  be  too  slow,  I  give,  with 
or  without  it,  strophanthus,  in  doses  of  from  one  to  six 
drops  of  the  tincture,  or  sulphate  of  sparteine.  Of  the 
latter  an  infant  a  year  old  should  take  gr.  Y^q  or  ^  (6-15 
mgm.)  four  times  a  day  as  a  matter  of  precaution,  and 
every  hour  or  two  hours  in  an  emergency. 

Of  the  same  importance  are  alcoholic  stimulants.  The 
advice  to  wait  for  positive  symptoms  of  heart  failure  and 
collapse  before  employing  the  life-saving  apparatus  is 
bad.  There  are  cases  which  will  get  well  without  treat- 
ment, but  we  do  not  know  beforehand  which  they  will 
be.  No  alleged  mild  case  is  safe  until  recovery  has  taken 
place.  WTien  heart  failure  has  once  set  in — and  it  fre- 
quently occurs  in  apparently  mild  cases — our  efforts  are 
too  often  in  vain.  Thus  alcoholic  stimulants  ought  to  be 
given  early  and  often,  and  in  large  quantities,  thoroughly 
diluted.  There  is  no  such  thing  as  danger  from  them 
or  intoxication  in  septic  diseases — 100  c.c.  (3  iii.)  daily 
may  suffice,  but  I  have  often  seen  300  c.c.  (3  ix.)  or  more 

196 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

daily  of  brandy  or  whiskey  save  children  who  had  been 
doing  badly  with  100  c.c.  (3  iii.). 

Caffeine,  or,  in  its  stead,  coffee,  is  an  excellent  cardiac 
tonic,  except  in  those  cases  in  which  the  brain  is  suffering 
from  active  congestion.  For  subcutaneous  injections  the 
salicylate  (or  benzoate)  of  caffeine  and  sodium,  which 
readily  dissolves  in  two  parts  of  water,  is  invaluable  for 
emergencies,  in  occasional  doses  of  from  gr.  i-v.  (6  to  30 
cgm.)  in  from  m  ij.-x.  of  water.  From  gr.  v.-xx  (0.3-1.25) 
of  camphor  may  be  given  daily,  as  camphor  water,  or  in 
a  mucilaginous  emulsion,  which  is  easily  taken.  It  does  not 
so  disturb  the  stomach  as  carbonate  of  ammonium  is  apt 
to  do.  For  rapid  effect  it  may  be  administered  hypoder- 
mically,  in  four  to  five  parts  of  sweet  almond  oil,  which 
is  milder  and  more  convenient  than  ether.  Strychnine 
may  be  added  regularly  from  the  beginning  of  danger, 
and  mainly  in  cases  with  little  increase  of  temperature. 
Its  effect  is  more  than  momentarily  stimulating.  A  child 
of  three  years  will  take  gr.  %20  (0-5  mgm.)  three  times 
a  day,  and  much  more  in  an  urgent  case,  and  then  subcu- 
taneously.  But  the  very  best  internal  stimulant  in  urgent 
cases  is  Siberian  musk.  I  prefer  to  give  it  from  a  bottle, 
in  which  it  is  simply  shaken  up  with  a  thin  mucilage. 
In  urgent  cases  it  ought  to  be  administered  in  sufficient 
doses  and  at  short  intervals.  When  ten  or  fifteen  grains 
given  to  a  child  one  or  two  years  old  within  three  or 
four  hours  will  not  restore  the  heart's  action  to  a  more 
satisfactory  standard,  the  prognosis  is  very  bad. 

Nephritis^  parenchymatous,  interstitial,  and  glomerular, 
and  the  varieties  of  pneumonia  are  frequent  complications 
or  consequences  of  diphtheria.  The  treatment  of  either 
of  them  requires  no  particular  disclission  in  this  place. 
Nor  does  oedema  of  the  glottis  yield  indications  differing 
from  those  of  the  same  affection  occurring  from  other 
causes. 

Diphtheria  of  the  skin  and  of  the  sexual  organs  requires 
disinfectant  ointments.  I  have  mostly  relied  on  iodoform 
one  part,  in   from  eight  to  twelve  parts  of   fat. 

Diphtheritic  paralysis,  though  of  manifold  anatomical 
and  histological  origin,  yields  in  all  cases  a  certain  num- 

197 


DR.    JACOBI'S    WORKS 

ber  of  identical  therapeutical  indications.  These  are  the 
sustaining  of  the  strength  of  the  heart  by  digitalis  and 
other  cardiac  tonics.  This  is  an  indication  on  which  I 
cannot  dwell  too  much.  Many  of  the  acute,  and  most  of 
the  chronic,  diseases  of  all  ages  do  very  much  better  by 
adding  to  other  medication  a  regular  dose  of  a  cardiac 
tonic.  While  it  is  a  good  practice  to  follow  the  golden 
rule  to  prescribe  simply,  and  if  possible  a  single  remedj'^ 
only,  it  is  a  better  one  to  prescribe  efficiently. 

Besides,  there  are  some  more  indications :  mild  prepara- 
tions of  iron,  provided  the  digestive  organs  are  not  inter- 
fered with;  strychnine,  or  other  preparations  of  nux 
vomica,  at  all  events ;  in  ordinary  cases  a  child  of  three 
years  will  take  gr.  YgQ  three  or  four  times  a  day  ("to- 
gether 0.002  gm.).  Local  friction,  massage  of  the  throat, 
of  the  extremities,  and  trunk,  dry  or  with  hot  water,  or 
oil,  or  water  and  alcohol;  and  the  use  of  both  the  inter- 
rupted and  continuous  currents,  according  to  the  known 
rules  and  the  locality  of  the  suffering  parts,  find  their 
ready  indications.  The  paralysis  of  the  respiratory  mus- 
cles is  quite  dangerous ;  the  apnoea  resulting  from  it  may 
prove  fatal  in  a  short  time.  In  such  cases  the  electric 
current  used  for  short  periods,  but  very  frequently,  and 
hypodermic  injections  of  sulphate  of  strychnine  in  more 
than  text-book  doses,  and  frequently  repeated,  will  render 
good  service.  I  remember  a  case  in  which  these,  with  the 
occasional  use  of  an  interrupted  current,  and  occasional 
artificial  respiration  by  Sylvester's  method,  persevered  in 
for  the  better  part  of  three  days,  proved  effective.  In  a 
few  cases  of  diphtheritic  paralysis  the  use  of  antitoxin 
appeared  to  score  a  success.  Other  forms  of  paralysis 
(hemiplegia,  ataxia)  demand  a  treatment  like  the  above, 
modified   by  their   peculiar   circumstances   or   symptoms. 

Orrhotherapy. — The  use  of  diphtheria  antitoxin  has 
been  discussed  several  times  on  previous  pages,  mainly  as 
regards  its  effect  as  an  immunizing  agent  and  its  action 
in  laryngeal  diphtheria.  It  has  passed  its  experimental 
stage  as  safely  as  if  it  had  been  employed  these  fifty  years, 
and  has  created  a  literature  of  its  own  on  which  bacteriolo- 
gists,  chemists,  medical   and   surgical   clinicians,   practical 

198 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

men  and  theorists,  friends  and  enemies  have  been  at  work. 
No  matter  what  the  nature  of  its  action  may  be,  whether 
when  injected  under  the  skin  of  a  diphtheria  patient  it 
supplements  the  antidote  created  by  the  toxin  of  diph- 
theria in  the  blood  or  the  cells  of  the  patient,  or  whether 
it  aids  the  antitoxin  into  which  the  toxin  is  believed  by 
some  to  be  changed  (Buchner,  Smirnow,  Metchnikoff)  or 
which  is  the  product  of  reaction  (Behring,  Ehrlich^), 
this  action  can  no  longer  be  doubted.  Discussions  on  that 
point  are  fruitless.  When  the  injection  is  to  be  made,  the 
syringe  should  be  sterilized  each  time,  for  no  poison  is  en- 
tirely safe.  A  carbolic-acid  solution  of  five  per  cent.,  and 
absolute  alcohol  will  suffice  for  that  purpose.  The  injection 
should  be  made  into  a  loose  and  copious  subcutaneous  tis- 
sue, not  into  the  skin,  and  not  into  muscles.  The  abdomen- 
is  more  sensitive  than  the  lumbar  region  and  the  thigh, 
and  the  subscapular  or  intrascapular  region.  The  latter 
should  not  be  selected  unless  the  subcutaneous  tissue  is 
quite  abundant.  According  to  the  severity  of  the  case  six 
hundred,  one  thousand,  fifteen  hundred  or  two  thousand 
"units"  should  be  injected.  The  dose  should  be  repeated 
unless  the  symptoms — both  constitutional  and  local — be 
improved  within  twelve  or  twenty-four  hours.  Sixty-five 
hundred  units  were  successfully  used  in  a  bad  case  of  noma 
of  the  vulva,  in  which  diphtheria  and  putrefactive  bacteria 
were  found  by  Petrushky  (Deutsche  medicinische  Wochen- 
schrift,  1898).  The  puncture  should  be  covered  with  an 
antiseptic   gauze,   or  with   iodoform   collodion. 

A  "  unit "  is  equivalent  to  1  c.c.  of  what  is  called  "  nor- 
mal serum."  Normal  serum  is  the  blood  serum  of  an 
immunized  animal  which  was  made  so  efficacious  that  0.1 
c.c.  antagonizes  ten  times  the  minimum  of  diphtheria  poison 
fatal  to  a  guinea-pig  weighing  300  gm.  (about  10  ounces). 

The  universal  demand  is  for  early  injection.  There  is 
unanimity  in  the  experience  that  the  prognosis  is  impaired 
by  procrastination.     The  latest  report  from  Vienna  is  only 

6  Ehrlich  thinks  the  antitoxin  is  the  result  of  functional  over- 
exertion of  the  cell  protoplasm  which  has  been  irritated  by  the 
circulating  toxin,  and  compares  this  process  with  the  hypertrophy 
of  overexerted  organs. 

199 


DR.    JACOBI'S    WORKS 

a  repetition  of  what  has  been  known  these  four  years. 
When  antitoxin  was  injected  on  the  first  and  second  day, 
only  6.7  per  cent,  of  all  the  cases  died,  on  the  third  19, 
on  the  fourth  23,  on  the  fifth  31,  on  the  sixth  33.3  per 
cent. 

This  fact  has  become  so  fixed  in  the  minds  of  many 
practitioners  who  believe  themselves  responsible  for  the 
welfare  of  their  patients,  that  in  doubtful  cases  in  which 
the  diagnosis  of  "  diphtheria  "  or  "  pseudodiphtheria  " 
has  not  been  made  on  account  of  time,  and  in  view  of  the 
innocuousness  of  antitoxin  when  injected  unnecessarily, 
and  believing  that  whatever  discomforts  there  may  arise 
after  the  injection  do  not  compare  with  the  danger  of  the 
disease  when  not  combated  in  time,  they  "  inject  the  an- 
.titoxin  and  settle  the  question  of  diagnosis  afterwards  " 
(Charles  G.  Jennings  in  Medical  Age,  February  25th, 
1898).  In  general  that  practice  is  to  be  recommended  in 
bad  cases  and  bad  seasons,  for  the  bacteriological  diag- 
nosis can  be  completed  before  another  injection  is  required, 
if  at  all. 

All  forms  of  diphtheria  are  liable  to  be  benefited  by 
antitoxin,  from  the  simplest  to  the  septic,  from  the  un- 
complicated to  the  mixed,  the  latter  less  than  the  former. 
It  is  this  mixed  form  in  which  I  look  upon  the  neglect 
of  other  treatment,  both  local  and  general,  as  simply 
criminal.  The  statistics  both  of  hospitals  and  of  private 
practice  have  grown  immensely,  and  are  daily  growing; 
they  are  the  staple  article  of  our  journal  literature.  I 
would  therefore  refer  the  reader  to  what  I  quoted  in 
my  "  Therapeutics  of  Infancy  and  Childhood,"  and  will 
conclude  with  a  few  of  those  data  which  are  quite 
recent. 

Of  the  report  of  the  diphtheria  committee  of  the  Clini- 
cal Society  of  London  The  Lancet  (June  4th,  1898)  pub- 
lishes what  follows : 

"  For  the  purpose  of  the  inquiry  832  reports  of  cases 
were  collected,  but  upon  examination  199  of  them  had  to 
be  rejected,  either  because  the  committee  were  not  satisfied 
as  to  the  evidence  of  diphtheria  or  because  the  amount  of 
antitoxin    administered    was    not    stated    in    normal    units, 

200 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

leaving  633  available  for  further  analysis.  Of  the  cases 
which  presented  symptoms  more  or  less  severe  of  laryngeal 
aiFection  nearly  one-half  escaped  the  operation  of  tracheot- 
omy, a  very  much  larger  proportion  than  is  usually  the 
case  in  laryngeal  diphtheria  treated  in  other  ways.  The 
tracheotomies  performed  may  be  divided  into  two  groups : 
(a)  Tracheotomy  within  twenty-four  hours  of  the  first 
injection,  and  (&)  tracheotomy  at  a  later  period.  Only 
2  out  of  the  75  belong  to  group  (6).  The  committee 
drew  especial  attention  to  these  f^cts,  and  also  to  the  re- 
sults of  the  operation  of  tracheotomy,  in  which  the  mor- 
tality amounted  to  36  per  cent.,  as  opposed  to  71.6  per 
cent,  in  the  control  series  compiled  from  the  records  of  the 
general  hospitals  before  the  introduction  of  antitoxin.  The 
mortality  fell  as  age  increased,  but  it  was  in  the  first  five 
years  of  life  that  the  lessened  mortality  in  the  antitoxin 
series  was  most  marked.  It  was  to  the  lesser  frequency 
with  which  membrane  extended  to  the  larynx  and  trachea 
in  cases  treated  by  antitoxin  and  to  the  effect  of  the  anti- 
toxin on  them  when  membrane  was  present  that  the  less- 
ened mortality  in  the  antitoxin  series  was  mainly  due. 
The  total  mortality  in  the  633  cases  amounted  to  124,  or 
19-5  per  cent.,  as  opposed  to  29-6  per  cent,  in  the  non- 
antitoxin  control  series.  Not  only  was  the  mortality  in  the 
antitoxin  series  much  less  than  in  the  other,  but  the  dura- 
tion of  life  in  the  fatal  cases  was  longer,  a  fact  which 
has  considerable  bearing  on  the  frequency  with  which 
paralytic  symptoms  occurred.  The  closest  investigation 
failed  to  discover  any  connection  between  the  occurrence 
of  paralysis  and  the  amount  of  antitoxin  injected,  nor 
did  the  period  of  the  disease  at  which  it  was  first  used 
appear  to  exert  any  influence  on  the  occurrence  of  paralytic 
symptoms.  Some  form  or  other  of  rash  followed  the  in- 
jection of  antitoxin  serum  in  very  nearly  a  third  of  the 
cases.  The  rashes  could  be  divided  into  two  main  types: 
those  which  were  of  an  erythematous  and  those  of  an 
urticarial  character;  the  former  largely  predominated.  In 
no  instance  did  the  presence  of  a  rash  appear  to  have  any 
bearing  on  the  ultimate  result  of  the  case.  Joint  pains 
which  were  not  met  with  in  the  non-antitoxin  series   and 

201 


DR.    JACOBI'S    WORKS 

were  apparently  due  to  the  antitoxic  serum  were  observed 
in  a  small  number  of  cases.  The  percentage  of  deaths 
with  suppression  of  urine  was  found  to  be  practically 
the  same  in  the  antitoxin  and  the  non-antitoxin  series. 
The  general  result  of  the  inquiry  showed  that  in  the  cases 
treated  with  antitoxin  not  only  was  the  mortality  notably 
lessened,  but  the  duration  of  life  in  fatal  cases  was  also 
prolonged.  The  injection  of  antitoxin  may  produce  rashes, 
joint  pains,  and  fever;  with  these  exceptions  no  prejudicial 
action  has  been  observed  in  the  series  of  cases  investigated 
to  follow  even  in  cases  in  which  a  very  large  amount 
of  antitoxin  serum  has  been  used." 

According  to  Buchwald  (Miinchner  medicinische  JVochen- 
schrift,  1898,  No.  14)  of  563  patients  treated  without 
antitoxin,  57.72  per  cent,  died;  of  311  treated  with  it, 
28.93  per  cent.  died.  Tracheotomies  were  required  in  57 
per  cent,  in  the  ante-serum  period,  in  30.86  per  cent,  dur- 
ing the  serum  time.  Albuminuria  was  observed  in  36.65 
per  cent,  of  all  the  injected  cases,  paralysis  in  93  cases, 
exanthems  in  74,  pain  in  joints,  without  swelling,  however, 
in  2,  otorrhoea  in  10,  bronchopneumonia  in  36  cases.  Most 
of  the  latter  were  fatal.  Besides  antitoxin,  good  nutrition, 
stimulants,  and  irrigation  of  the  nose  and  mouth  were  em- 
ployed. 

Axel  Johannessen  communicated  to  the  Moscow  Con- 
gress a  report  covering  1131  cases  of  diphtheria  observed 
during  1890  by  71  Norway  physicians.  Those  cases  were 
treated  with  antitoxin;  there  were  73  deaths  (6.5  per 
cent.) ;  this  percentage  is  reducible  to  5.3  per  cent,  by 
deducting  the  cases  that  came  under  treatment  while  mori- 
bund. From  1867  to  1893,  before  the  antitoxin  period, 
the  mortality  was   23.5    per   cent. 

Escherich  had  in  Prague  a  mortality  of  9  per  cent., 
compared  with  36   per  cent,   of  former  times. 

John  E.  Walsh  (New  York  Medical  Journal,  June  18th, 
1898)  publishes  the  following  figures.  In  1895-96  there 
were  treated  in  the  District  of  Columbia: 

Cases  with  antitoxin 174;    died,  23=13.2  per  cent. 

Cases   without   antitoxin,  152;       "      53=34.9        " 

202 


DIPHTHERIA:  SYMPTOMS  AND  TREATMENT 

In  1896-97  there  were: 

Cases  with  antitoxin, 285;  died,  21=  7.3  per  cent. 

Cases    without    antitoxin,  335;       "      89^26.6        " 

Of  the  285  antitoxin  cases  there  were  238  below  twelve 
years,  with  a  mortality  of  8.9  per  cent.;  of  the  335  non- 
antitoxin  cases  there  were  256  below  twelve  years,  with 
a  mortality  of  33  per  cent.  Of  86  over  twelve  years 
treated  with  antitoxin  none  died;  of  113  of  the  same  age 
treated  without  antitoxin,  8  died.  In  the  last  seven  months 
preceding  the  publication  422  cases  were  treated:  211 
with  antitoxin  and  a  mortality  of  8,  or  3.8  per  cent. ; 
190  without  antitoxin  and  a  mortality  of  65,  or  34.2  per 
cent.,  as  in  the  pre-antitoxin  period.  The  treatment  em- 
ployed  in   21    cases   was   unknown   to   the   writer. 

Among  the  very  latest  statistics  are  those  of  Kronlein 
(Ziirich),  who  reported  to  the  Twenty-seventh  Congress  of 
German  Surgeons  (April,  1898)  on  1773  cases  of  diph- 
theria observed  in  the  clinical  hospitals  of  the  university 
during  the  years  1881-97.  A  recapitulation  of  the  results 
is  presented  in  the  following  table: 


Pre-Antitoxin  Period 

Antitoxin  Period 

"Old  croup 
room." 
1881-1889 

New  diphthe- 
ria house 

1889-1894 

H      00 

00 

New  diphthe- 
ria house 
1894-1897 

Total 

485 
230 

47.4jg 
354 
211 

59.6^ 
131 

19 

14.5^ 

851 
304 

35.7% 
308 
227 

73.7^ 
543 

77 

14.1^ 

1,336 
534 

39.9^ 
662 
438 

66.1^ 
674 

96 

14.2^ 

1 

437 

Deaths 

Mortality 

Operations 

Deaths    

Mortality    

Cases  not  operated 

Deaths    

Mortality 

55 

12.5^ 
17 
36 

35.6;^ 
336 
19 
5.6^ 

In  all  the  437  cases  in  the  antitoxin  period  the  Klebs- 
Lceffler    bacillus    was    demonstrated.      Kronlein's    statistics 

203 


DR.    JACOBI'S    WORKS 

prove  the  following  facts:  While  the  morbidity  of  the 
whole  district  (city  and  country)  remained  unaltered  in 
the  antitoxin  period,  the  mortality  decreased  considerably 
— mainly  in  the  surgical  clinic,  in  operated  (tracheotomy 
or  intubation)  or  non-operated  cases,  and  principally  in 
the  first  years  of  life.  While  previous  to  the  institution 
of  antitoxin  treatment  one-half  of  all  the  cases  had  to 
be  operated  upon,  this  percentage  has  fallen  to  23.1  per 
cent,  since  that  time. 

After  the  injection  of  antitoxin  improvement  set  in 
speedily;  the  temperature  diminished;  the  deposits  on,  and 
the  membranes  in,  the  throat  and  air  passages  soon 
loosened,  and  the  diphtheritic  secretion  of  the  nose  be- 
came speedily  less ;  the  lymphadenitis  of  the  neck  dimin- 
ished; the  diphtheria  process  did  not  descend  into  the  air 
passages;  mild  laryngostenosis  did  not  increase;  there  was 
no  diphtheric  infection  of  the  tracheotomy  wound,  which 
was  observed  in  one-third  of  all  the  cases  of  former  times; 
and  the  tube  could  be  removed  as  early  as  the  third, 
fourth,   or   fifth   day   after   tracheotomy. 

During  the  same  period  albuminuria  was  observed  in 
S6.6  per  cent,  of  all  cases  of  diphtheria,  pronounced  ne- 
phritis in  4.6  per  cent.,  and  postdiphtheritic  paralysis  in 
12.5  per  cent.  Exanthems  of  the  most  various  forms, 
with  mild  general  symptoms  only,  were  met  with  in  8 
per  cent. ;  they  were  attributed  to  the  serum.  None  was 
found  after  small  injections  made  for  the  purpose  of  im- 
munizing healthy  persons. 

To  gainsay,  with  such  statistics  at  hand,  the  superiority 
of  antitoxin  to  any  other  single  remedy  known  to  us  for 
diphtheria  is  a  foolhardy  undertaking.  But  there  are  some 
drawbacks  met  in  its  employment  which  are  acknowledged 
by  all,  and  exaggerated  by  some.  I  refer  to  disagreeable 
symptoms  with  which  the  administration  of  antitoxin  is 
charged,  and  which  are  said  to  take  place  in  the  blood, 
on  the  skin,  in  the  joints,  in  the  respiratory,  circulatory, 
urinary,  digestive,  and  nervous  systems.  Even  sudden 
death  has  been  claimed  as  one  of  the  results  of  antitoxin 
injections. 

Dr.  James  Ewing  studied  the  effects  of  antitoxin  on  the 

204 


DIPHTHERIA:  SYMPTOMS  AND  TREATMENT 

number  and  nature  of  leucocytes  {Nem  York  Medical  Jour- 
nal, August  17th,  1895).  While  leucocytosis  begins  a  few 
hours  after  the  invasion  of  diphtheria,  and  increases  mainly 
as  regards  myelocytes  (uninuclear  and  neutrophilic  gran- 
ules which  are  never  found  in  the  lymph  nodes)  up  to  the 
climax  of  the  disease,  and  steadily  declines  during  con- 
valescence— remaining  high  only  in  most  of  the  bad  and 
fatal  cases — antitoxin  causes,  according  to  Ewing,  a  re- 
duction of  the  number  of  leucocytes  within  thirty  minutes 
after  the  injection.  This  reduction  affects  mainly  the 
uninuclear  leucocytes,  while  the  proportion  of  well-stained 
multinuclear  cells  is  increased.  In  favorable  cases  tht 
leucocytosis  never  again  reaches  its  original  height 
after  the  injection;  in  severe  and  very  bad  cases  it  is 
followed  in  a  few  hours  by  more  leucocytosis  and  fever. 
In  very  bad  cases  the  immediate  result  may  be  either 
rapid  increase  or  decrease  of  leucocytes,  and  death.  The 
multinuclear  leucocytes  found  in  the  blood  in  favorable 
cases  after  treatment  with  antitoxin  show  an  increased  af- 
finity for  gentian  violet.  This  change  may  be  observed 
within  twelve  hours  after  the  injection,  and  its  non-oc- 
currence is  a  very  unfavorable  prognostic  sign. 

John  S.  Billings,  Jr.,  found  after  the  employment  of 
antitoxin  some  little  diminution  in  the  number  of  blood 
cells.  In  six  cases  so  treated  he  met  with  a  steady  rise, 
and  the  decrease  of  haemoglobin  was  less  marked  than  in 
cases  of  uninfluenced  diphtheria. 

Urticaria,  sometimes  with  increased  temperature,  simple 
or  complicated  with  erythema  (simple,  or  multiform,  or 
exudative  with  or  without  extravasation)  is  observed  at 
different  times,  very  soon  or  a  few  days  after  the  injection 
round  the  puncture,  or  after  one  or  more  weeks  in  different 
parts  of  the  body.  Now  and  then  the  efflorescence  requires 
some  predisposition,  for  it  has  been  noticed  in  one  child 
of  a  family  while  the  rest  remained  free.  Horse  serum 
containing  no  antitoxin  is  known  to  have  caused  the  same 
eruption ;  this  effect  appears  to  be  more  marked  in  the 
serum  of  one  horse  than  in  that  of  another.  It  is  similar 
to  what  hag  been  observed  after  transfusion  of  the  blood 
of  heteroggnpug  animals.     The  small  amount  of  carbolic 

205 


DR.    JACOBI'S    WORKS 

acid  contained  in  the  antitoxin  should  not  be  held  re- 
sponsible for  the  eruption;  nor  can  the  local  irritation  be 
charged  with  causing  eruptions  which  take  a  week  or  weeks 
to  develop.  Altogether  this  urticaria  behaves  like  the 
vasomotor  or  neuropathic  cutaneous  irritations  observed  in 
predisposed  persons  after  the  use  of  oysters,  crabs,  or 
strawberries. 

Herpes  (nasal,  labial,  aural)  has  been  noticed  in  a  few 
instances,  notably  by  Baginsky,  and  by  Mya,  who  observed 
at  the  same  time  a  "  critical  "  fall  of  the  temperature  of 
the  body. 

Other  forms  of  eruptions,  macular,  papular,  and  erythe- 
matous, also  petechiae  with  or  without  larger  extravasations, 
have  been  recorded.  Desquamation  is  observed  in  pro- 
portion to  the  degree  of  dermatitis.  Some  observers  speak 
of  many  cases,  others  of  few,  others  (Rumpf)  never  saw 
any  eruption. 

W.  T.  Coues  reports  fifty  cases  of  antitoxin  injections 
for  the  purpose  of  immunization.  A  child  of  five  years 
received  five  hundred  units,  a  baby  of  one  day  fifty,  those 
under  six  months  three  hundred,  under  a  year  four  hun- 
dred. The  older  children  were  not  affected  in  the  least; 
the  infants  were  restless  and  cried  long  after  the  injec- 
tion. The'  temperature  of  three  infants  reached  101° 
F.  five  hours  after  the  injection;  the  next  morning  it  was 
normal.  On  the  morning  following  the  injections  the 
younger  children  had  slight  coughs,  which  passed  away  in 
two  or  three  days.  Urticaria  occurred  in  14  cases  out  of 
the  50  inj  ected ;  a  punctated  erythema  in  2 ;  in  1  there 
were  soreness  and  pain  in  the  right  knee-joint,  which 
passed  off  in  two  days  {Boston  Medical  and  Surgical 
Journal,  July  14th,  1898). 

Abscesses,  occasionally  with  lymphangitis,  have  been  ob- 
served by  Monti,  Variot,  and  others.  When  they  occurred, 
fault  was  found  with  the  serum  which  was  not  considered 
germ-free,  or  with  the  skin  which  was  charged  with  not 
having  been  aseptic,  or  with  the  undue  thickness  of  the 
needle  and  subsequent  infection  of  the  wound,  or  with 
the  perforation  of  too  many  layers  of  tissue  down  into  the 
muscles,  or  with  the  condition  of  the  syringe,  which  it  is 

206 


DIPHTHERIA:    SYMPTOMS    AND     TREATMENT 

difficult,  no  matter  whether  the  piston  is  leather  or  asbestos, 
to  render  absolutely  safe.  In  a  few  instances  symptoms 
were  observed  which  were  attributed  to  the  entrance  of 
air  into  a  small  vein. 

Arthropathies  were  noticed  with  or  without  exanthems. 
Swelling  and  pain  of  a  knee  or  an  ankle-joint  were  noticed 
a  few  times,  together  with  urticaria  in  the  second  week 
after  an  injection.  These  lasted  a  day  or  a  week  or 
more.  They  are  not  frequent,  for  there  are  observers  who 
have  never  seen  them  in  any  of  a  large  number  of  cases. 
It  should  not  be  forgotten  that  they  are  symptoms  which 
occasionally  occur  in  diphtheria  not  treated  with  anti- 
toxin. 

Lymph  bodies  now  and  then  swell  after  an  antitoxin  in- 
jection, but  only  in  connection  with  an  eruption  or  an 
arthropathy. 

Antitoxin  has  been  charged  with  causing  pneumonia. 
The  latter  is  so  frequent  a  complication  of  diphtheria  in 
all  its  stages  that  the  attempt  to  substantiate  the  charge 
seems  hazardous.  If  antitoxin  affects  the  mucous  mem- 
branes favorably  it  is  not  likely  to  produce  bronchitis  or 
pneumonia.  Possibly  Lennox  Browne  feared  this  alleged 
effect  when  he  considered  the  use  of  antitoxin  contra- 
indicated  during  the  existence  of  a  bronchopneumonia. 

It  has  also  been  accused  of  developing  a  latent  tuber- 
culosis into  one  of  more  rapid  progress.  That  is  barely 
possible,  inasmuch  as  every  fever,  for  instance  after  vac- 
cination, is  held  to  have  a  similar  effect.  But  it  is  very 
much  more  probable  that  the  invasion  of  the  Klebs-Loeffler 
bacilli  and  of  the  streptococci  of  the  diphtheritic  attack, 
according  to  previous  statements  referring  to  their  com- 
plications with  tubercle  bacilli,  leads  to  the  outbreak. 

A  secondary  fever,  lasting  a  day  or  longer,  has  been 
observed  after  ten  or  fourteen  days;  it  often  coincides 
with  an  eruption  of  urticaria,  and  seems  to  be  a  legiti- 
mate symptom  of  the  latter.  In  most  cases,  however,  an- 
other etiology  is  more  probable.  It  is  more  often  con- 
nected with  the  diphtheria  than  with  the  antitoxin  treat- 
ment. In  many  cases  there  may  be  a  new  invasion,  mostly 
cocci;  there  may  be  an  abscess,  a  rhinitis,  a  tuberculosis. 

207 


DR.    JACOBI'S    WORKS 

With  an  abscess,  or  still  more  commonly  with  rhinitis, 
lymph  bodies  will  swell  and  the  temperature  will  rise. 

After  an  injection  of  antitoxin  vomiting  and  diarrhoea 
have  been  noticed  and  have  been  explained  as  the  result 
of  intoxication  with  a  fibrin  ferment.  On  the  other  hand, 
Baginsky  is  positive  that  he  has  geen  those  symptoms  less 
often  after  antitoxin  than  in  cases  of  diphtheria  not  so 
treated.  It  appears  not  improbable  that  the  blind  confi- 
dence in  antitoxin  has  something  to  do  with  an  occasional 
case  of  gastrointestinal  irritation.  For  with  some  every 
other  treatment  is  neglected,  while  antitoxin  is  being  ad- 
ministered, and  it  is  quite  possible  that  abundant  mem- 
branes not  removed  by  irrigation,  while  being  rapidly 
loosened  and  thrown  oiF,  are  swallowed. 

Albuminuria  and  nephritis  are  not  at  all  met  with  after 
the  injection  of  antitoxin  by  some  observers  (Riether  in 
none  of  1450  cases)  ;  frequently  by  others  (Soltmann  in 
72  per  cent.).  They  occur  within  a  week.  Sorensen  re- 
ports no  albuminuria  when  he  operated  with  Danish  serum, 
but  many  cases  after  the  use  of  French  serum.  That  ex- 
perience would  go  to  show  that  either  the  normal  horse 
serums  were  different,  or  that  the  preparation  of  the  an- 
titoxin was  not  identical.  The  small  amount  of  phenol 
contained  in  it  should  not  be  accused,  for  it  is  too  minute 
even  to  be  discovered  in  the  urine.  What  should  not  be 
overlooked  is  the  fact  that  both  albuminuria  and  nephritis 
are  common  occurrences,  beginning  in  the  very  first  week 
of  a  diphtheria,  sometimes  within  a  few  days,  before  an- 
titoxin is  administered  or  has  had  time  to  take  effect. 
Among  181  cases  of  Heubner's  of  those  injected  on  the 
first  day  of  the  disease  five-sixths  remained  free;  on  the 
second,  two-thirds ;  on  the  third,  one-half ;  on  the  fourth, 
one-third.  In  525  cases  of  Baginsky's  treated  with  anti- 
toxin there  was  albuminuria  in  40.95  per  cent.,  clinical 
nephritis  in  12.57  per  cent.,  and  post-mortem  nephritis  in 
15.80  per  cent.  However,  among  933  treated  without  an- 
titoxin there  was  albuminuria  in  42  per  cent.,  clinical 
nephritis  in  25.78  per  cent.,  and  post-mortem  nephritis  in 
16.31  per  cent. — rather  a  favorable  showing  for  antitoxin. 
In  Strassburg   (Sieger,  in  Virchow's  Archiv,  1897)    renal 

208 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

affections  were  frequent  after  the  injection  of  antitoxin; 
but  though  some  of  them  lasted  weeks  or  months,  they 
were  benign  and  without  morphological  elements  in  the 
urine. 

In  some  cases  albuminuria  will  change,  either  totally 
or  partially,  into  albumosuria,  under  what  appears  to  be 
bacterial  or  antitoxin  influence. 

The  existence  of  the  after-effects  is  not  denied  by  any 
of  the  most  enthusiastic  admirers  of  antitoxin,  but  it  is 
claimed  by  all  that  no  serious  or  lasting  bad  results  fol- 
low, and  that  if  every  life  threatened  by  diphtheria  were 
known  to  be  protected  by  the  alleged  untoward  or  uncom- 
fortable effects  of  the  remedy,  we  should  willingly  submit 
to  them  in  every  case.  The  balance  of  what  we  know  of 
antitoxin  is  thus  far  favorable,  and  this  addition  to  our 
therapeutical  powers  will  forever  be  remembered  as  cred- 
itable to  Emil  Behring.  The  lack  of  recognition  which 
was  some  time  ago  withheld  from  him  by  many  was,  most 
unfortunately,  his  own  fault.  The  morbid  vanity  and  some 
personal  motives  displayed  in  almost  every  one  of  his 
writings  tallied  so  badly  with  the  tendencies  and  the  spirit 
of  a  scientific  benefactor  as  to  render  suspicious  both  his 
veracity  and  his  motives.^  Still,  the  grateful  medical  pro- 
fession and  the  public  will  not  forget  his  work.  That  his 
preoccupation  and  his  limited  horizon  should  dwarf  his 
judgment  is  a  matter  of  regret.  It  is  a  pity  he  is  not  a 
clinician,  but  only  a  scientific  famulus.  If  he  were  a 
clinician  he  would  not  have  been  tempted  into  asserting 
that  organotherapy  has  accomplished  nothing,  that  cellular 
pathology  has  proved  sterile,  that  remedies  combat  main 
symptoms  only,  that  medicine  has  had  hitherto  therapeuti- 
cal principles   only  but  no   therapeutical   experimentation, 

7  This  was  written  in  the  first  edition  of  my  "  Therapeutics  of 
Infancy  and  Childhood"  some  years  ago.  Those  who  thought  I 
was  too  severe  in  criticising  the  motives  of  the  man  have  since 
learned  that  he  has  obtained  in  this  countrj-,  where  no  physician 
deigns  or  would  dare  to  descend  into  the  arena  of  bargaining  and 
shop-keeping,  a  patent  right  on  his  wares,  which  I  am  credibly 
informed  secured  him  more  than  a  million  marks  in  a  single  vear 
in  his  countrv- 

209 


DR.    JACOBI'S    WORKS 

and  that  his  experimental  therapeutics  is  in  conscious  op- 
position to  medication  (German  Congress  for  Internal 
Medicine,  June,  1897). 

Behring  himself  explains  the  occurrence  of  undesirable 
effects  of  his  serum  only  by  the  accidental  and  indifferent 
albuminoids  and  salts  contained  in  the  serum.  They  are 
according  to  him  greatly  reduced  by  increasing  concentra- 
tion, even  to  the  dry  state  which  he  succeeded  in  obtain- 
ing. In  the  concentration  the  antitoxin  is  "  absolutely 
uninjurious,  without  poisonous  effects  in  man  or  animal, 
healthy  or  sick."  According  to  H.  C.  Ernst,  J.  N. 
Cooledge,  and  H.  A.  Cooke  (Journal  of  the  Boston  Society 
of  Medical  Science,  May,  1898),  the  antitoxic  property 
of  antidiphtheritic  serum  can  be  removed  from  one  part 
of  the  serum  and  added  to  another  by  a  method  of  frac- 
tional freezing,  the  bottom  layers  showing  greater  strength. 
By  this  method  serum  of  high  potency,  more  or  less  per- 
manent, can  be  obtained. 

Like  Behring,  Henry  W.  Berg  (Medical  Record,  June 
18th,  1898)  attributes  undesirable  effects,  eruptions  follow- 
ing the  administration  of  antitoxin,  to  some  original 
impurity.  "  It  is  probable,  almost  certain,  that  many 
of  the  eruptions  are  due  to  a  toxalbumin  contained  in  the 
serum  of  the  horse  which  should  be  strained  through  a 
fine  Chamberland  filter.  Neither  the  pure  serum  of 
the  horse  nor  the  diphtheria  antitoxin  loses  any  of  its  power 
by   filtration." 

The  adversaries  of  antitoxin  have  tried  to  make  it  re- 
sponsible for  diphtheritic  paralysis,  without  any  reason. 
It  is  true  that  there  are  many  cases  of  paralysis  occurring 
in  children  previously  treated  with  antitoxin,  but  it  has 
always  appeared  to  me  that  the  number  was  swelled  by 
some  of  those  who  would  have  succumbed  without  anti- 
toxin long  before  the  period  of  paralysis  was  due.  Ap- 
parently mild  cases  of  diphtheria  are  followed  by  paraly- 
sis ;  it  is  certainly  true  that  many  a  case  is  changed  into 
a  mild  one  by  antitoxin.  .  It  is  after  all  better  to  have 
a  paralytic  child  with  the  great  probability  of  a  final  re- 
covery than  a  corpse  without  even  a  chance  of  paralysis. 
Moreover,   I  cannot  imagine  a  more  difficult  task  than  to 

210 


DIPHTHERIA:     SYMPTOMS     AND     TREATMENT 

calculate  statistics  on  totally  absent  bases.  The  average 
number  of  paralyses  varies  according  to  the  cases,  the  se- 
verity of  the  epidemics,  and  probably  to  the  treatment 
also.  And  finally,  large  numbers  of  cases,  like  those  of 
Baginsky,  appear  to  prove  the  contrary  of  what  has 
been  alleged.  Among  993  patients  before  serum  therapy 
was  introduced  there  were  68  cases  of  paralysis,  or  6.8 
per  cent.;  among  525  in  the  antitoxin  period  there  were 
27,  or  5.14  per  cent.  Schmidt  Rimpler  feels  certain  that 
his  patients  with  accommodation  paralysis  recovered  more 
speedily  under  the  use  of  antitoxin  than  without  it. 

Sudden  deaths  have  occurred  after  the  injection  of  anti- 
toxin, the  doses  being  in  some  instances  quite  small.  The 
case  of  the  Langerhans  child  in  Berlin,  who  died  after 
having  received  an  injection  of  antitoxin,  is  not  explained 
in  spite  or  because  of  loud  vituperations  and  vilifications. 
Most  reporters  of  cases  have  been  satisfied  with  the  admit- 
ting they  know  of  no  explanation.  Belin  publishes  one 
of  the  latest  cases,  and  admits  that  death  cannot  positively 
be  attributed  to  the  influence  of  the  serum.  Nifong  {Med- 
ical Review,  May  7th,  1898)  gave  a  boy  of  fifteen  years, 
of  slight  build  and  with  feeble  circulation,  fifteen  hundred 
units.  After  ten  minutes  there  were  pallor,  numbness  of 
the  extremities,  cyanosis,  swelling  of  the  face,  and  vom- 
iting. Death  occurred  in  thirty-five  minutes.  Two  girls 
received  the  same  dose  of  the  same  serum  obtained  from 
the  city  chemist  of  St.  Louis  without  a  bad  result. 

Rauschenbusch  observed  on  his  four-year-old  daughter, 
who  had  taken  three  times  the  dose  while  sick  with  diph- 
theria two  years  previously,  pruritus,  urticaria,  vomiting, 
sopor,  and  heart  failure  after  two  hundred  units  injected 
for  the  purpose  of  immunization.  It  does  not  appear  that 
a  connection  between  heart  failure  and  sudden  death  on 
the  one  hand  and  antitoxin  on  the  other  has  been  estab- 
lished in  any  case,  and  venturesome  and  generalizing 
speculations  are  not  able  to  shed  light  on  obscure  subjects. 
At  all  events,  a  single  finding,  a  suggestion,  or  a  suspicion 
of  vomiting  and  aspiration  of  a  solid  body  into  the  air 
passages,  or  of  the  inpection  of  air  into  a  vein,  or  excite- 
ment and  fright,  or  a  lymphatic  state,  or  a  large  thymus, 

211 


DR.    JACOBJ'S    WORKS 

if  at  all  applicable  to  an  individual  case,  does  not  permit 
of  a  universal  interpretation. 

After  all,  we  can  well  agree  with  the  conclusions  of 
Dieudonne  when  he  says  that  the  treatment  of  diphtheria 
with  serum  is  an  essential  advance  in  therapeutics,  that 
its  effect  is  more  frequently  favorable  than  that  of  former 
methods,  and  that  accessory  consequences  do  not  outweigh 
the  useful  effects. 

H.  Biggs  recapitulates  many  of  his  previous  writings  in 
a  paper  read  before  the  Society  of  the  Alumni  of  Belle- 
vue  Hospital,  as  follows:  "  Since  the  introduction  of  an- 
titoxin treatment  the  mortality  of  diphtheria  is  reduced 
to  one-half,  its  course  is  shorter  and  milder ;  an  in j  ection 
made  within  the  first  two  days  reduces  the  mortality  to 
five  per  cent. ;  the  earlier  it  is  made  the  better  the  result. 
Small  quantities  of  concentrated  serum  are  tolerated  by  the 
very  youngest  babies.  If  antitoxin  is  not  a  specific  it  is 
certainly  the  best  remedy  in  our  possession  against  diph- 
theria. The  genuine  (that  is,  uncomplicated  bacillary) 
cases  are  more  amenable  to  its  favorable  influence  than 
mixed  infections.  It  has  no  secondary  effects  on  heart, 
kidneys,  or  nerves.  Heart  failure  and  paralysis  whenever 
observed  are  caused  by  diphtheria,  not  by  antitoxin." 


SI!? 


THE  PATHOLOGY  AND  TREATMENT  OF  THE 
DIFFERENT  FORMS  OF  CROUP 

The  term  of  "  Croup  "  has  been  applied  to  many  widely 
different  conditions.  All  of  these  conditions,  however, 
have  one  symptom  in  common,  viz.,  dyspnoea,  or  attacks 
of  dyspnoea,  bordering  on  suffocation,  and  depending  on 
local  obstruction  of  the,  or  in  the,  larynx.  As  I  do  not 
pretend  to  give  an  essay  on  croup  complete  in  all  its  bear- 
ings, I  simply  refer  to  the  immense  number  of  text-books, 
articles,  essays,  and  monographs  written  on  the  subject. 
The  subject  of  this  paper  is  wholly  practical,  mostly  clin- 
ical. It  is  based  almost  exclusively  on  my  own  observa- 
tions, examinations,  and  experience.  Thus,  if  I  have  to 
spend  some  time  in  speaking  of  things  known  to  all,  I 
beg  your  i)ardon  and  indulgence ;  and  for  what  I  have  to 
state  that  is  unexpected  or  uncalled  for,  your  approbation 
or  refutation. 

The  mildest  form  of  what  is  frequently  called  croup, 
and  in  severe  cases  may  actually  prove  deserving  of  the 
name,  is  acute  catarrh  of  the  larynx.  Its  causes  are  very 
numerous.  Inhalation  of  cold  air,  of  dust,  or  other  irri- 
tants ;  contact  of  a  hot  liquid  with  the  lining  membrane  of 
the  larynx;  over-exertion  of  the  voice;  the  influence  of 
cold  temperature  diminishing  that  of  the  body,  particu- 
larly neck,  throat,  and  feet,  and  mostly  in  individuals  with 
thin  epidermis  and  a  great  tendency  to  copious  perspira- 
tion ;  spreading  of  the  catarrhal  process  from  the  nose  or 
bronchi,  or  the  pharynx,  for  instance  after  the  inordinate 
use  of  snuff  or  alcohol,  to  the  larynx,  in  the  contiguity  of 
the  tissue.  Besides,  there  are  a  number  of  general  diseases, 
which  are  complicated  with,  or  exhibit  amongst  their  symp- 
toms,  a   catarrh    of  the   larynx ;    thus    measles,    scarlatina, 

213 


DR.    JACOBI'S    WORKS 

variola,  erysipelas,  typhus  and  typhoid  fever,  and  influ- 
enza. 

The  anatomical  lesions  found  in  persons  who  have  died 
while  affected  with  catarrh  of  the  larynx  do  not  always 
correspond  with  the  symptoms  encountered  during  life. 
The  mucous  membrane  of  the  larynx  is  so  replete  with 
elastic  fibres  that  after  death  even,  the  blood  is  squeezed 
out  of  the  dilated  capillaries.  In  very  severe  forms  of 
catarrh,  small  apoplexies,  ecchymoses  occur  now  and  then, 
and  will  be  found  after  death,  occasionally.  The  mucous 
membrane  is  denuded  of  the  normal  vibratile  cylindrical  epi- 
thelium which  forms  the  uppermost  epithelial  layer  of  the 
larynx.  The  mucous  membrane  is  reddened,  moist,  succu- 
lent, loose  in  its  tissue;  the  sub-mucous  tissue  is  now  and 
then  (Edematous,  and  sometimes,  even  in  an  acute  catarrh  of 
quite  a  recent  date,  small  superficial  ulcerations  have  been 
found.  Thus  the  anatomical  changes  left  in  the  mucous 
membrane  of  the  larynx,  after  death,  fully  correspond 
with  those  found  in  the  mucous  membranes  of  other  organs. 
Sometimes  the  traces  of  catarrh  are  clear  and  distinct, 
soipetimes  nothing  is  found  in  post-mortem  examinations. 
An  example  of  this  fact  is  the  occasional  absence  of  all 
and  any  post-mortem  results  in  children  who  have  died 
in  a  severe  attack  of  gastro-intestinal  catarrh,  so-called 
cholera  infantum.  While  in  some  there  are  all  the  traces 
of  catarrh,  and  its  sequelae,  from  simple  hyperaemia  to 
follicular  ulceration,  there  is  no  alteration  in  others. 

The  acute  catarrh  of  the  larynx,  as  mentioned,  with  its 
capillary  injection,  its  throwing  off  and  rapid  disintegra- 
tion of  the  epithelium,  and  its  (Edematous  infiltration,  is 
by  no  means  universal  in  all  cases.  In  some,  the  epiglottis, 
or  the  mucous  membrane  of  the  inferior  vocal  cords,  or 
the  Wrisbergian,  Santorinian,  and  arytenoid  cartilages; 
the  aryepiglottic  folds,  the  true  vocal  cords,  or  the  in- 
ferior part  of  the  larynx,  may  be  affected  either  separately 
or  contemporaneously,  with  or  without  a  similar  affection 
of  the  contiguous  regions  between  nose,  pharynx,  and 
lungs.  The  symptoms  of  the  affection  will  frequently  vary 
in  correspondence  with  these  anatomical  differences. 

The  acute  catarrh  of  the  larynx  is  seldom,  from  the  be- 

214 


TREATMENT    OF    CROUP 

ginning^  a  feverish  disease.  The  patients  feel  comfortable, 
and  the  functions  of  the  diseased  organ  alone  are  abnor- 
mal. There  is  a  certain  degree  of  sensibility  in  the  region 
of  the  larynx,  a  burning  or  itching  sensation.  The  voice 
is  altered,  becoming  indistinct  and  hoarse,  in  consequence 
of  the  thickening  of  the  margins  of  the  vocal  cords,  which 
the  muscles  are  no  longer  able  to  force  into  as  many  vi- 
brations as  before.  Besides  the  itching  and  burning  sen- 
sation, and  hoarseness,  there  is  another  symptom  present, 
namely,  severe  cough,  occurring  in  paroxysms,  as  if  pro- 
duced by  some  foreign  body  touching  the  mucous  membrane 
of  the  larynx.  Expectoration  is  not  copious;  in  the  com- 
mencement of  the  disease  there  is  none,  or  it  is  clear  and 
serous,  containing  some  few  cylindrical  epithelia,  and  a 
few  from  the  lower  layers.  In  the  other  stages  of  the 
disease,  particularly  in  the  course  of  recovery,  the  expec- 
toration becomes  more  consistent,  more  purulent,  and  yel- 
lowish. In  a  somewhat  advanced  age  only  will  children 
remove  their  expectoration  voluntarily;  they  will  swallow 
whatever  touches  their  fauces,  and  therefore  it  is  very 
difficult  sometimes  to  obtain  any  information  as  to  the 
nature  of  the  expectorated  substances.  Physical  explora- 
tion by  means  of  the  laryngoscope  yields,  at  this  age, 
and  with  the  uncontrollability  of  most  children,  but  few 
results. 

The  sub-mucous  tissue  is  much  swollen  in  some  excep- 
tional cases  only,  as  far  as  adult  persons  are  concerned. 
For  the  glottis,  and  particularly  its  posterior  third,  forms 
a  pretty  large  opening  in  adults,  and  the  entrance  of  air 
into  the  respiratory  organs  is  not  prevented  by  the  tume- 
faction of  the  mucous  membrane.  Even  children  do  not 
suffer  very  often  from  constant  dyspnoea,  in  consequence 
of  a  simple  laryngeal  catarrh.  Although  in  them  the  glot- 
tis is  short  and  narrow,  the  swollen  chordae  vocal es,  by 
means  of  the  constant  and  uninterrupted  action  of  the  pos- 
terior crico-arytenoid  muscles,  are  sufficiently  distant  from 
each  other  not  to  prevent  the  entrance  of  air.  But  some- 
times children,  who  have  been  coughing  and  hoarse  during 
the  day,  without  feeling  sick,  will  be  observed  to  awake 
suddenly  in  the  night,  with  an  attack  of  suffocation.     In- 

215 


DR.    JACOBI'S    WORKS 

spiration  is  extremely  difficult  and  exhausting;  in  the  ut- 
most height  of  their  anxiety  and  trouble,  the  children  will 
roll  about,  stretch  their  necks  and  grasp  their  throats ; 
their  cough  is  hoarse,  rough,  barking.  These  attacks  have 
been  and  are  very  often  mistaken  for  croup,  have  been 
and  are  described  as  pseudo-croup,  false  croup,  and  usually 
disappear  without  leaving  a  trace,  after  a  duration  of  one 
or  a  few  hours.  These  are  the  attacks  which  readily  dis- 
appear after  the  administration  of  hot  milk,  or  hot  sponges 
over  neck  and  throat,  and  by  emetics,  and  which  have  won 
for  these  remedies  the  reputation  of  being  infallible  in 
croup,  when  given  in  time.  You  may  be  certain  that  all 
the  children  who  are  reported  to  have  suffered  from  croup 
four,  six,  and  twelve  times,  and  have  always  been  saved 
were  simply  suffering  from  attacks  similar  to  those  of  which 
I  have  just  been  speaking.  Perhaps  the  sudden  attacks  of 
suffocation  are  produced  by  a  momentary  swelling  of  the 
mucous  membrane  and  narrowing  of  the  glottis,  which  the 
muscular  action  could  not  counteract,  as  sometimes  a  nos- 
tril is  thoroughly  impermeable  in  consequence  of  a  severe 
cold.  But  it  is  better  explained  in  the  following  manner: 
The  suffocative  attacks  almost  always  occur  in  the  course 
of  the  night;  they  diminish  and  disappear,  after  the  child 
has  been  awake  for  a  time,  with  screaming,  coughing,  and 
vomiting;  and  will  appear  anew  after  the  patient  has 
again  fallen  asleep.  From  this  fact  it  is  probable  that 
the  cause  of  the  sudden  suffocative  attacks  is  due  to  the 
exsiccation  of  a  collection  of  tough  secretion  in  the  larynx 
and  glottis.  At  all  events,  the  quick  operation  of  the  above- 
mentioned  remedies  is  best  explained  in  this  manner.  Thus 
I  always  give  the  advice,  during  the  first  two  nights  of 
an  acute  laryngeal  catarrh,  not  to  let  the  children  sleep 
beyond  a  certain  time.  Awake  them  from  time  to  time 
and  let  them  drink.  I  prefer  them  to  cough  more  fre- 
quently and  mildly  to  exposing  them  to  violent  spells  of 
both    coughing   and    dyspnoea. 

Some  have  attributed  a  large  part  of  the  symptoms  to 
spasm;  the  affection  has  even  been  called  spasmodic  laryn- 
gitis. Now,  actually  every  cough,  no  matter  of  what  sort, 
is  a  convulsive  action,  but  this  is  not  the  meaning  of  those 

216 


TREATMENT    OF    CROUP 

who  emphasize  the  spasmodic  element  in  this  aiFection. 
They  lay  stress  on  the  presence  of  a  constant  spasmodic 
condition  of  the  glottis.  But  the  intermission  of  the 
symptoms  refutes  that  assumption,  and  the  only  real  af- 
fection of  the  glottis  in  this  disease,  namely,  thickening 
of  the  vocal  cords,  resulting  in  obstruction,  excludes  in- 
termission in  toto.  Moreover,  the  sound  of  the  cough  is 
hoarse,  or  barking.  Those,  however,  who  are  acquainted 
with  the  inspiratory  spasm  of  the  glottis,  or  the  inspiratory 
muscles,  that  is,  diaphragm,  intercostales,  scaleni,  serrati, 
as  in  whooping  cough  and  in  laryngismus  stridulus,  or 
so-called  crowing  inspiration  of  children,  know  that  the 
convulsive  sound  is  sibilant,  higher  in  the  scale,  in  conse- 
quence of  the  narrowing  of  the  glottis.  The  same  sound 
is  produced  even  in  expiratory  spasm,  which,  however,  is 
ver}"^  rare.  It  is  known  that,  under  common  circumstances, 
expiration  is  simply  the  passive  result  of  the  elasticity 
of  the  lung  tissue.  Thus  expiration  is  always  incomplete, 
part  of  the  gas  remaining  in  the  lungs.  It  may  become 
more  complete  by  the  aid  of  the  abdominal  muscles,  espe- 
cially the  transversus  abdominis.  Thus  we  can  speak  of 
expiratory  spasm  or  paralysis  in  some,  though  rare,  cases, 
but  even  in  these  the  sound  of  the  cough,  and  the  inter- 
mission of  the  symptoms,  refute  the  presence  of  a  spas- 
modic element  in  acute  catarrh  of  the  larynx.  We  are  but 
too  prone  to  fall  back,  for  the  explanation  of  pathological 
symptoms,  on  the  nervous  system,  of  which  we  know  still 
less  than  of  the  rest.  Facts  frequently  disagree  with  our 
comfort  and  convenience. 

Thus  far  I  have  mentioned  but  such  symptoms  of  acute 
laryngeal  catarrh  which,  as  slight  swelling  of  the  mucous 
membrane,  oedematous  infiltrations  of  the  sub-mucous  tis- 
sue, and  occasional  dyspnoea,  will  readily  get  well  either 
spontaneously  or  on  expectative  or  simple  treatment.  It  is 
easily  understood,  however,  that  the  symptoms  may  be 
grave  in  consequence  of  real  and  complete  obstruction  or 
closure  of  the  glottis. 

This  may  be  the  result  of  two  different  conditions: 
1.  Direct  contraction  of  the  lumen  of  the  glottis  by  con- 
siderable tumefaction   of  the  true  vocal  cords;    by   tume- 

217 


DR.    JACOBI'S    WORKS 

faction  of  the  inferior  vocal  cords  covering  the  inner  mar- 
gin of  the  superior  ones ;  by  swelling  of  the  posterior  wall 
of  the  larynx;  and  by  an  accumulation  of  secretion  brought 
about  by  the  impeded  function  of  the  congested  and  (Edema- 
tous larynx. 

2.  Deficient  dilatability  of  the  glottis,  that  is,  impeded 
motion  of  the  arytenoid  cartilages,  and  the  true  vocal  cords ; 
by  swelling  of  the  integuments  of  the  Santorinian  and 
arytenoid  cartilages,  and  subsequent  immobility  of  these 
cartilages  and  the  true  vocal  cords  inserting  on  the  vocal 
processes;  and,  finally,  by  paralysis  of  dilating  muscles. 

When  such  complete  obstruction  takes  place,  the  same 
symptoms  as  those  of  membranous  croup,  or  foreign  bodies, 
or  polypous  growths,  or  acute  oedema,  obstructing  the  wind- 
pipe, will  appear,  with  the  same  indications  and  the  same 
results,  unless  these  indications  are  fulfilled. 

As  to  the  course,  duration,  and  termination  of  the  milder 
form  of  acute  catarrh  of  the  larynx,  it  may  be  added  that 
usually  after  a  few  days  the  larynx  ceases  to  be  as  sensi- 
tive, the  cough  subsides,  the  hoarseness  vanishes,  and  the 
disease  terminates  in  recovery,  after  a  week  or  two.  But 
a  duration  of  several  weeks  is  not  uncommon,  and  do  not 
forget  that  the  infantile  organism  has  a  great  tendency 
to  inflammatory  affections,  and  to  the  exudative  processes, 
and  that  the  infantile  vocal  cords  will  not  bear  so  well 
as  those  of  adults,  a  thickening  of  their  substance  and  a 
considerable  narrowing  of  the  rima  glottidis.  The  patient 
may  be  apparently  well  during  the  day  but  troubled  by 
attacks  of  coughing  every  morning  and  night,  and  this 
state  of  things  may  last  for  a  long  time,  until  the  catarrh 
and  its  consequences  have  become  chronic,  and  removable 
with  difficulty  only.  But  more  serious  consequences  may 
follow  the  slightest  dyspnoea,  continuing  for  a  long  time; 
a  smaller  amount  of  oxygen  enters  the  blood  than  is  neces- 
sary for  normal  combustion,  and  for  a  complete  and  regular 
physiological  metamorphosis  of  the  organism.  This  is 
undoubtedly  proved  by  the  assertions  even  of  adult  patients, 
suffering  from  slight  laryngeal  catarrh,  who  will  experience 
suffocative  attacks,  and  surprise  you  by  showing  a  mass 
of  mucus  brought  up  after  long  coughing,  dry,  hard,  some- 

218 


TREATMENT    OF    CROUP 

times  slightly  tinged  with  blood,  and  exactly  bearing  the 
outlines  of  Morgagni's  fossae  between  the  superior  and  in- 
ferior vocal  cords,  or  some  other  part  of  the  larynx. 

It  is  a  remarkable  incident  that  just  the  reverse  of  what 
has  been  presumed  to  be  correct,  is  so.  The  fact  that 
children  die  of  croup,  who  on  the  post-mortem  table  do  not 
exhibit  much  anatomical  obstruction  in  the  larynx,  proves 
a  paralysis  rather  than  a  spasm  of  the  larynx.  Animals 
whose  pneumogastric  nerves  have  been  cut,  and  whose  glot- 
tis is  paralyzed  in  consequence,  die  with  the  exact  dyspnoea 
of  croup.  Moreover,  let  us  consider  for  a  moment  in  which 
condition  the  mucous  membrane,  the  sub-mucous  tissue, 
and  the  muscles  of  the  larynx  may  be  found.  There  is 
succulence,  swelling,  oedema.  There  is  in  consequence  of 
this  condition  of  the  mucous  membrane,  oedematous  infiltra- 
tion and  paleness  of  the  submucous  tissue  and  the  muscles. 
Thus,  to  prove  by  analogy,  in  pleuritis  the  intercostal 
muscles  are  paralyzed  and  bulging  out;  in  peritonitis  and 
enteritis  there  is  succulence,  oedema,  and  paralysis  of  the 
muscular  layer  of  the  intestine,  by  which  the  absence  of 
peristaltic  motion  and  the  prevalence  of  flatulency  and 
constipation  must  be  explained.  The  same  pathological 
fact  holds  good  for  the  several  constituent  tissues  of  the 
larynx. 

Further:  the  base  of  the  two  arytenoid  cartilages  form- 
ing (by  stretching  forward  and  inward)  the  vocal  processes, 
are  very  large  in  adults,  so  large,  indeed,  as  to  form  a 
triangular  surface,  the  "  pars  respiratoria  "  of  Longet. 
This  part  does  not  exist  in  children,  as  the  base  of  the 
cartilages  is  brt  narrow,  and  thus  the  glottis  from  anterior 
to  posterior  is  but  a  uniformly  narrow  slit  bordered  by 
the  vocal  cords.  Now  when  the  air  in  the  trachea  is  rare- 
fied and  a  full  current  of  air  falls  on  the  vocal  cords, 
and  the  dilators  of  the  vocal  cords,  namely,  the  posterior 
crico-arytenoid  muscles,  are  paralyzed,  the  vocal  cords, 
oblique  in  their  relation  to  each  other,  are  approximated, 
or  entirely  closed.  By  sucking  the  air  out  of  the  trachea 
of  a  child  from  below,  this  fact  can  easily  be  verified  in 
the  fresh  anatomical  specimen.  Thus  when  the  symptoms 
of  croup  are  the  result  of  membranous  obstruction  of  the 

219 


DR.    JACOBI'S    WORKS 

larynx,  both  inspiration  and  expiration  are  impeded;  when 
of  paralysis,  the  inspiration  suffers  more  seriously  than 
expiration.  This  latter  is  especially  the  case,  when  the 
pharynx  is  implicated  in  the  croupous  process,  as  in  so- 
called  descending  croup.  For  it  is  the  mucous  membrane 
of  the  pharynx  which  forms  the  integument  of  the  mm. 
crico-arytenoidei  portici,  which  in  normal  inspiration,  when 
healthy,  enlarge  the  glottis. 

As  far  as  the  treatment  of  acute  laryngeal  catarrh,  or 
spasmodic  laryngitis,  or  pseudo-croup,  is  concerned,  it  is 
better  to  accustom  healthy  children  to  the  usual  causes  of 
the  affection  than  to  guard  them  too  cautiously.  Such 
as  have  been  affected  before,  will  be  most  liable  to  be  taken 
sick  again.  They  ought  to  be  dressed  carefully  according 
to  the  temperature  of  the  atmosphere.  If  there  is  any- 
thing as  injurious  as  it  is  unsesthetical,  it  is  the  naked 
shoulder  and  leg  of  a  shivering  child.  But  they  ought  to 
be  accustomed  to  inhale  fresh  air,  and  to  the  free  use  of 
cold  water,  river  and  sea-bathing.  Such  will  be  the  most 
efficient  preventives.  Common  cases  of  acute  laryngeal 
catarrh,  produced  by  atmospheric  influences,  require  warm 
foot-baths  and  mild  diaphoretics,  hot  tea  or  milk,  subace- 
tate  of  ammonia,  tartar  emetic  in  small  doses ;  the  irrita- 
tion of  the  skin  by  hot  sponges,  sinapisms,  and  the  appli- 
cation of  cold  water  to  the  throat;  a  severe  attack  of  suffo- 
cation or  dyspnoea  will  now  and  then  require  an  emetic: 
ipecac  in  infants,  ipecac  with  tartar  emetic  in  more  ad- 
vanced age.  I  state,  however,  that  I  take  exception  to 
the  too  general  use  of  emetics  in  these  so-called  cases  of 
croup,  when  no  other  symptoms  but  hoarseness  or  a  bark- 
ing cough  show  themselves.  In  cases  of  serious  dyspnoea 
alone  they  ought  to  be  administered.  This  much  I  can 
assure,  that  not  one  out  of  a  dozen  of  the  children  en- 
trusted to  my  charge  are  punished  to  such  an  extent  in  this 
affection.  Wherever  a  complication  is  found  of  pharyngeal 
with  laryngeal  catarrh,  astringent  gargles  or  applications, 
or  inhalations  of  tannic  acid,  or  alum,  or  nitrate  of  silver, 
in  strong  solutions,  or  in  substance,  are  useful.  Even 
when  not  applied  to  the  larynx  directly,  they  will  frequently 
prove   beneficial   by    contracting   the   dilated   blood-vessels 

220 


TREATMENT    OF    CROUP 

of  the  contiguous  membrane,  and  thereby  influencing  the 
catarrhal  condition  of  the  larynx.  Permit  me,  however,  to 
exclude  from  this  remark  the  eff"ect  of  the  gargles.  If 
they  are  expected  to  have  the  same  influence  on  the  dis- 
tant portions  of  the  pharynx  and  the  larynx,  as  the  direct 
applications  by  the  probang,  no  matter  of  what  form,  or 
the  pulverizer,  their  effect  is  overestimated.  In  the  act  of 
gargling,  the  liquid  does  not  reach  further  than  the  velum 
pendulum,  and  the  anterior  aspect  of  the  tonsils  at  the 
best,  and  for  the  reason  of  this  plain  physiological  fact, 
that  whatever  is  thrown  beyond  will  certainly  be  swallowed 
and  not  ejected  again,  we  ought  not  to  expect  too  much 
from  their  use. 

No  blood-letting,  local  or  general,  is  beneficial.  Fatty 
food  is  injurious;  vegetable  acids  are  beneficial;  so  are 
alkalies.  Whether  the  chemical  composition  of  the  mucus, 
which  contains  more  chloride  of  sodium  than  the  blood, 
thereby  depriving  the  blood  of  this  salt,  or  the  physiologi- 
cal effect  of  bicarbonate  of  soda,  restoring  the  vibratile 
action  of  the  cylinder,  epithelium,  has  anything  to  do 
with  this  beneficent  effect,  I  hesitate  to  assert.  The  tem- 
perature of  the  sickroom  is  to  be  mild  and  uniform,  the 
air  moist,  and  every  exertion  of  the  larynx,  speaking, 
crying,  coughing,  must  be  avoided,  prevented,  or  prohibited. 
Many  an  attack  of  coughing  may  be  frowned  or  scolded 
down  in  older  children;  for  frequently  it  is  the  giving  in 
to  the  first  slight  irritation  to  cough  which  gives  rise  to 
a  severe  attack.  The  best  means,  however,  to  suppress 
the  irritation  of  the  laryngeal  mucous  membrane  is  the 
internal  administration  of  narcotics.  It  is  hardly  worth 
while  to  try  hyoscyamus,  belladonna,  hydrocyanic  acid. 
You  will  always  find  a  moderate  dose  of  Dover's  powder, 
or  morphia,  or  codeia,  administered  several  times  a  day,  or 
a  larger  dose  at  bed-time,  to  yield  a  favorable  effect 
in  soothing  the  irritated  mucous  membrane  of  the  larynx, 
and  in  suppressing,  or  at  least  diminishing,  the  trouble 
and  the  danger  from  continued  coughing. 

The  number  of  so-called  expectorants  administered  in 
laryngeal  catarrh,  as  in  that  of  the  rest  of  the  mucous 
membrane  of  the  respiratory  organs,  is  very  large  indeed; 

2^1 


DR.    JACOBI'S    WORKS 

ipecac^  squill,  senega,  tartar  emetic,  sanguinaria,  and  id 
genus  omne.  My  own  opinion  of  their  value  is  not  very 
great.  I  hardly  ever  prescribe  them.  As  this  is  so,  I 
have  to  beg  your  pardon  for  swelling  their  number  by  two 
others.  One  is  the  oxysulphuret  of  antimony,  similar  in 
its  chemical  composition  to  kermes  mineral,  on  the  expec- 
torant qualities  of  which  I  published  an  essay  in  the  New 
York  Journal  of  Medicine,  ten  years  ago.  After  the  fever 
of  catarrhal  affections  has  subsided,  and  where  no  diar- 
rhoea is  present,  and  the  powers  of  the  patient  not  ab- 
solutely low,  it  may  be  given,  in  doses  of  from  one-fourth 
to  two  grains,  from  four  to  eight  times  a  day.  It  does 
not  exhibit  the  depressing  nor  the  purgative  effect  of 
other  antimonials,  although  after  a  while  it  will  be  dis- 
covered in  the  passages,  unchanged;  and  may  be  given 
as  a  powder,  or  in  mixtures,  with  or  without  adjuvants, 
or  sedatives.  The  other  is  the  hydrochlorate  of  ammonia, 
or  chloride  of  ammonia.  The  so-called  resolvent,  anti- 
neuralgic,  anti-rheumatic  effects  of  this  salt  have  been 
mentioned,  and  sometimes  extolled,  in  Great  Britain  and  in 
our  country.  It  was  sometimes  spoken  of  as  a  powerful 
remedy,  undoubtedly  because  of  its  being  an  ammoniacal 
preparation ;  and  I  have  sometimes  read,  and  heard  of  late, 
of  its  wonderful  effect,  and  the  possibility  of  its  being  a 
dangerous  drug.  The  truth  is,  that  its  powers  of  both 
injuring  and  benefiting  have  been  greatly  exaggerated. 
For  decennia,  while  it  was  comparatively  unknown,  and 
sometimes  feared,  in  England  and  America,  it  was  the 
common  accommodation  drug  of  German  practitioners. 
In  doubtful  and  plain  cases,  danger  or  not,  indication 
or  not,  if  no  other  innocent  or  convenient  thing  would 
strike  the  non-inventive  genius  of  the  practitioner,  chloride 
of  ammonia  was  resorted  to.  It  was  the  squills  or  the 
calomel  of  the  Englishman.  You  would  find  as  many 
recipes  with  chloride  of  ammonia  on  the  counters  of  a 
German,  as  calomel  on  those  of  an  English  drug  store. 
Thus  it  may  be  considered  probable  that  its  strong  or  in- 
jurious effects  cannot  be  very  marked.  What  I  can  say 
of  it  is  this:  I  have  no  high  opinion  of  its  effects  ex- 
cept  those    referable    to    the    mucous    membrane,    particu- 

222 


TREATMENT    OF    CROUP 

larly  of  the  respiratory  organs.  Its  effects  on  the  mucous 
membrane  of  the  stomach  and  intestines  are  far  inferior 
to  those  which  may  be  obtained  by  a  judicious  use  of 
emetics,  alkalies,  and  acids,  especially  the  bicarbonate  of 
soda,  and  the  muriatic,  or  the  nitromuriatic  acids,  or  the 
usual  salts  of  silver  or  bismuth.  But  its  effects  on  the 
mucous  membrane  of  the  trachea,  larynx,  and  bronchi  are 
marked,  in  all  such  cases,  but  in  those  cases  only,  in  which 
the  liquefaction  of  a  tough,  hard,  viscid  secretion  is  re- 
quired. In  a  catarrhal  affection,  when  the  fever  has 
subsided,  and  expectoration  appears  insufficient,  it  will  be 
administered  with  marked  benefit.  Here,  and  here  only, 
lies  its  sphere.  It  may  be  given  in  doses  of  gr.  xx.  or  gr. 
xl.  a  day,  with  or  without  a  sedative  to  diminsh  local  nerv- 
ous irritation,  hyoscyamus  or  belladonna;  and  will  be  ad- 
vantageously combined  with  the  same  amount  of  chlorate 
of  potassa  or  a  somewhat  larger  dose  of  chlorate  of  soda, 
in  complications  with  catarrh  of  the  pharynx.  It  may  be 
given  through  the  day,  while  towards  bed-time,  or  at 
nine  or  ten  o'clock,  a  sufficient  single  dose  of  opium,  or 
an  opiate,  may  be  administered.  Such  are  the  outlines  of 
the  rules  according  to  which  the  usual  form  of  laryngeal 
catarrh  ought  to  be  treated.  Those  forms,  however,  in 
which  a  complete  obstruction,  or  an  almost  complete  closure 
of  the  larynx  takes  place,  from  such  causes  as  enumerated 
before,  and  in  which  the  above  treatment  proves  ineffi- 
cient, require  other  means  to  ward  off  the  fatal  termina- 
tion by  suffocation.  These  are  the  forms  which  deserve 
the  name  of  catarrhal  croup,  and  require  as  sound  and 
quick  a  judgment  as  a  steady  hand.  They  are  not  fre- 
quent, but  they  will  occur,  in  every  land  and  practice. 
Just  as  surely  as  a  case  of  polypus,  or  foreign  body  in  the 
larynx  requiring  interference,  may  be  met  with  any  day, 
although  sometimes  not  in  a  dozen  years,  a  case  of  catar- 
rhal croup  threatening  speedy  death  from  suffocation  may 
be  met  with.  Every  physician  is  acquainted  with  the 
occurrence  of  acute  oedema  of  the  glottis,  and  the  necessity 
for  establishing  an  artificial  entrance  of  air  into  the  lungs, 
and  every  one  may  meet  with  a  case  of  catarrhal  croup  in 
which  the  omission  of  tracheotomy  is  homicide. 

223 


DR.    JACOBI'S    WORKS 

Dr.  Kiihn  has  collected  149  cases  of  foreign  bodies  in 
the  larynx,  treated  with  tracheotomy,  and  109  recoveries; 
73  cases  of  oedema  of  the  glottis,  and  54  recoveries;  52 
cases  of  syphilitic  laryngitis,  and  39  recoveries;  28  cases 
of  perichondritis  and  necrosis,  and  5  recoveries ;  4  cases 
of  angina  tonsillaris,  and  1  recovery;  22  cases  of  epilepsy, 
and  20  recoveries ;  1 1  cases  of  wounds  of  the  larynx,  and 
10  recoveries;  12  cases  of  combustion,  and  6  recoveries; 
35  cases  of  diseases  of  surrounding  organs,  and  5  recov- 
eries; 5  cases  of  polypi,  and  4  recoveries. 

Such  figures  are  reason  enough  why  the  name  of  those 
should  be  remembered  and  blessed  who  learned  and  taught 
to  temporarily  supply  the  lungs  and  blood  with  their  es- 
sential nutriment.  We  shall  soon  see  that  their  example  is 
not  only  valid  in  cases  of  walnut  shells,  bones,  copper 
pennies,  pieces  of  china,  coffee  beans,  pebbles,  and  sugared 
corn  imbedded  in  and  obstructing  the  air-passages,  but 
in  every  sort  of  air-passage  obstruction,  both  accidental 
and  pathological. 

From  our  considerations  of  the  treatment  of  croup,  how- 
ever, non-obstructing  catarrh  on  one  side,  foreign  bodies, 
polypi,  ulcerations,  with  oedematous  swelling,  as  in  typhoid 
fever,  typhus,  syphilis,  tuberculosis,  and  spasm  of  the  glot- 
tis, must  be  excluded.  The  diagnosis  of  true  croup  has 
for  a  long  period  been  thought  to  be  dependent  on  the 
presence  of  membranes,  and  consecutively  the  distinction 
between  croup  and  pseudo-croup,  according  to  their  pres- 
ence or  absence,  was  considered  uiiimpeachable.  But  there 
are  a  number  of  cases  on  record  in  which  tracheotomy  was 
performed  for  croup,  and  no  membranes  found.  Or  after 
pseudo-croup  had  lasted  and  been  diagnosticated  for  days, 
all  at  once  membranes  were  found  in  the  larynx,  with 
the  exclusion  of  the  pharynx.  Or  in  other  cases  the  symp- 
toms were  so  urgent  that  tracheotomy  was  performed 
for  what  was  shown  to  be  simple  catarrh  with  consider- 
able oedema,  and  with  or  without  pharyngeal  membranes. 
And  sometimes  the  membranous  deposit  was  found  in  the 
pharynx  alone,  and  nothing  beside  it,  after  death.  For 
these  reasons  a  diphtheritic,  a  membranous,  a  catarrhal 
and   spasmodic  croup  were  distinguished.     But  this  much 

224 


TREATMENT    OF    CROUP 

may  be  stated  here,  and  practitioners  will  admit  the  fact, 
that  the  affection  will  frequently,  especially  when  there 
is  no  epidemic  diphtheria,  commence  by  "  pseudo-croup," 
and  afterward  assume  a  more  formidable  character.  As 
this  is  so,  the  possibility  of  cutting  the  process  short 
by  proper  dietetic  measures,  provided  always  that  there 
is  no  constitutional  diphtheria,  cannot  altogether  be  denied. 
The  unbiased  examination  of  all  these  cases  of  croup 
met  with  yields  but  one  common  and  essential  symptom, 
namely,  obstruction  of  the  larynx,  from  a  nutritive  dis- 
order. Its  form  will  differ.  Of  the  anatomy  of  simple 
obstructing  catarrh  I  have  spoken.  Another  form  is  the 
follicular  process  of  the  tonsils  with  its  subsequent  changes, 
the  formerly  so-called  herpetic  angina  of  the  trachea, 
which  I  have  characterized  already  in  a  paper  on  diph- 
theria, published  in  August,  1 860,  in  the  New  York  Medi- 
cal Times.  It  is  exudative,  membranous  in  character,  fever- 
less,  but  will  not  unfrequently  be  followed  by  larger 
croupous  or  diphtheritic  deposits.  Another  form  is  the 
membranous  deposit  proper,  a  fibrinous  exudation,  amor- 
phous in  character,  mixed  with  mucus  and  blood  corpus- 
cles and  normal  epithelium.  It  is  either  deposited  upon 
the  mucous  membrane,  and  then  can  be  easily  lifted  up 
from  it,  or  into  it  and  into  its  subjacent  tissue.  The  first 
form  has  frequently  been  called  croupous,  the  latter  diph- 
theritic. But  whatever  clinical  difference  there  may  be 
between  a  simple  membranous  inflammation  and  consti- 
tutional diphtheria,  there  is  no  anatomical  difference  be- 
tween the  membranes  wherever  they  make  their  appearance. 
Another  form,  and  not  a  very  unfrequent  one,  is  originally 
confined  to  the  epithelium,  which  rapidly  undergoes  fatty 
degeneration  which  may  or  may  not  be  complicated  with 
fibrinous  exudation.  The  soft,  pultaceous,  easily  macerating 
diphtheritic  masses  are  of  this  character;  and  the  fearful 
cases  of  diphtheria  with  rapid  necrosis  of  the  tissue  are 
usualh^  of  the  same  nature.  The  neighborhood  may  be  in 
different  conditions,  cedematous  or  dry,  hyperaemic  or 
anaemic.  CEdematous  and  hyperaemic  condition  is  more 
commonly  found ;  a  dry  condition  is  a  frequent  occurrence 
in  the  necrobiotic  process  of  that  fatty  degeneration ;  an- 

225 


DR.    JACOBI'S    WORKS 

semia  of  the  surrounding  parts,  or  interspersed  portions^ 
depends  on  compression  of  capillaries  by  infiltration,  which 
means  new-formed  cells  and  connective  tissue ;  moreover,  let 
us  not  forget  that  we  have  fortunately  passed  by  the  time 
when  the  nutritive  disorder  called  inflammation  was  al- 
ways thought  to  depend  on  previous  congestion  of  the 
parts. 

All  those  forms  of  change  of  tissue  are  not  found  un- 
complicated in  every  given  case.  When  large  surfaces 
are  taken  at  once,  you  may  see  in  the  mouth  a  catarrhal 
proliferation  or  croupous  condensation  of  the  epithelium, 
on  the  tonsils  a  diphtheritic  deposit  imbedded  in  the  tis- 
sue, on  the  larynx  and  trachea  a  plain  croupous  deposit, 
and  in  the  bronchi  a  muco-purulent  secretion.  And  again, 
under  the  same  endemic  and  epidemic  influences  you  will 
find  a  case  of  catarrh,  a  case  of  croup,  a  case  of  diph- 
theria, a  case  of  follicular  exudative  amygdalitis,  in  the 
same  family  in  the  same  week.  Thus  it  appears  that  in 
the  long  list  of  morbid  conditions  met  with,  catarrh  on 
one  side,  diphtheria  on  the  other,  are  but  the  starting 
and  terminating  points  between  which  all  the  different 
shapes  and  forms  may  be  registered  according  to  their 
dignity,  their  modification  depending  on  individual,  local, 
endemic  and  epidemic  influences;  the  onh^  form  which  is 
perhaps,  but  perhaps  only,  to  be  excluded,  being  the  necro- 
tizing diphtheria.  And  when  we  compare  the  clinical  nature 
of  the  affection  we  find  similar  differences.  The  affection 
may  be  local  without  fever,  or  simply  febril,  or  local  and 
obstructing,  or  obstructing  and  poisonous.  In  some  cases 
the  process  will  not  even  be  confined  to  the  respiratory 
organs,  but,  similar  to  the  rinderpest  of  animals,  the  di- 
gestive organs  will  participate  in  the  process,  and  skin, 
kidneys,  spleen,  may   follow. 

Thus  great  may  be  found  the  difference  of  the  anatomi- 
cal lesion  in  croup,  but  the  stenosis,  obstruction  of  the 
larynx,  is  the  common  symptom  of  all  forms. 

After  the  symptoms  of  tumefaction,  succulence,  and  in- 
creased secretion,  with  their  paralyzing  influence  on  the 
mobility  of  the  vocal  cords,  and  with  its  barking  or  sound- 
less voice  or  cough,  have  passed  by,  or  without  these  pre- 

226 


TREATMENT    OF    CROUP 

monitory  symptoms,  inspiration  becomes  impeded,  its  dura- 
tion prolonged,  and  its  sound  sibilant.  The  respiratory 
eiForts  are  increased  in  consequence;  the  levatores  alarum 
nasi  active,  the  muscles  of  the  thorax  overstrained.  Ex- 
piration short,  no  interval  between  expiration  and  inspira- 
tion, mouth  and  nostrils  open.  The  superior  portion  of  the 
thorax  flattened,  the  supra-clavicle  regions  sunk,  sternum 
and  scrobiculus  cord  is  drawn  in;  the  inferior  part  of  the 
abdomen  bulging  out;  larynx  and  trachea  ascend  and  de- 
send  considerably  with  every  expiration  and  inspiration  to 
compensate  for  the  diminished  amount  of  air  admitted 
to  the  lungs.  The  flushed  face  becomes  pale,  now  and 
then  the  child  is  soporous,  vomiting  will  occur  spontane- 
ously while  emetics  are  losing  their  eff"ect,  respiration  is 
superficial,  attacks  of  suiFocation  will  alternate  with  sopor. 
Sometimes  for  a  change,  entire  remissions,  mostly  in  the 
morning,  will  take  place,  and  the  child  breathe  more 
quietly  and  appear  more  comfortable,  until  with  an  attempt 
at  deep  inspiration,  exactly  like  animals  in  whom  the  pneu- 
mogastric  nerves  have  been  cut,  a  fearful  attack  of  suflFo- 
cation  sets  in. 

Part  of  these  symptoms  result  from  the  abnormal  amount 
of  carbonic  acid  retained  in  the  blood;  not  from  reten- 
tion of  the  blood  in  the  brain;  for  as  long  as  inspiration 
alone  is  impeded,  blood  is  not  repelled  into  the  brain, 
nor  into  the  integuments,  and  therefore  we  notice  no 
cyanotic  hue,  except  in  a  severe  attack  of  coughing,  or 
except  toward  the  fatal  termination  when  the  heart  is 
becoming  paralyzed  and  the  arteries  insufficiently  filled. 
Then  the  veins  are  dilated  by  the  circulation  being  im- 
peded. To  the  contrary,  when  the  elastic  lung  tissue,  not 
sufficiently  filled  with  air  of  normal  density,  aff'ords  more 
room  for  the  capillaries  to  dilate,  when  there  is  less  pres- 
sure on  the  walls  of  these  lung  capillaries,  the  result  is 
congestion,  catarrh,  bronchitis,  and  broncho-pneumonia  in- 
side, while  the  external  surface  is  the  paler.  Thus  bron- 
chial catarrh  and  bronchitis  with  its  sequelae — not,  however, 
croupous  pneumonia,  which  requires  other  causes — is  the 
direct  efl^ect  of  impeded  circulation,  and  therefore  the 
frequent  cause  of  death   even  after  tracheotomy  has   re- 

227 


DR.    JACOBI'S    WORKS 

lieved  the  dyspnoea.  Cyanosis^  and  impletion  of  the  veins 
generally,  is  the  result  both  of  impeded  expiration  and 
inspiration,  when  the  larynx  is  almost  fully  obstructed 
by  membranes.  As  expiration  can  be  attended  with  greater 
muscular  force  than  inspiration,  the  blood  will  effectually 
be  repelled  into  the  venous  system.  Thus  will  occur  direct 
brain  symptoms  not  depending  on  carbonic  acid  poison- 
ing; from  this  source  the  immense  and  dangerous  dilata- 
tion of  the  veins  of  the  neck  and  thyroid  gland  as  met  with 
in  many  cases  of  tracheotomy;  from  this  source  also,  local 
or  general  cyanosis.  With  the  exception  of  a  very  few 
cases  in  which  the  obstructing  membrane  is  fortunately 
expelled,  nothing  else  but  death  can  be  expected.  It  will 
ensue  from  gradual  paralysis,  or  sometimes  from  sudden 
suffocation  by  loose  or  nearly  loose  membranes  obstructing 
the  glottis. 

Among  the  most  dangerous  symptoms  in  the  final  de- 
velopment of  the  process,  I  mention  the  following  as  con- 
siderably impairing  the  prognosis: 

1.  Emetics    administered,    and    no    relief. 

2.  Emetics   administered,   and  no   effect. 

3.  Constant  increase  of  dyspnoea. 

4.  No  more  remissions  between  the  attacks  of  suffoca- 
tion. 

5.  Feeble,  frequent,  and  intermittent  radial  pulse,  the 
intermission  coinciding  with   inspiration. 

The  indications  for  the  treatment  of  croup  must  neces- 
sarily be  dependent  on  its  anatomical  and  physiological 
character. 

The  character  of  croup  is:  suffocation  by  insufficient 
or  absent  entrance  of  air  into  the  lungs  in  consequence 
of  a  nutritive  disorder  of  the  larynx. 

The  obstructing  causes  are  either  oedematous  swelling, 
or  paralysis  of  vocal  cords,  or  presence  of  membranes,  or 
two  or  all  of  these  factors.  The  indication  is  to  remove 
the  one  or  all  of  them  by  the  proper  means,  and  to  pre- 
vent the  morbid  process  from  increasing.  To  give  a  list 
of  the  remedies  which  have  been  given  in  croup  for  the 
purpose  of  drenching  the  blood  and  system  with  a  "  sol- 
vent,"   "  antiplastic,"    etc.,    remedy,   would   be   to   write    a 

228 


TREATMENT    OF    CROUP 

list  of  almost  every  remedial  agent  of  the  pharmacopoeia, 
and  would  be  only  a  further  proof  of  the  well-known  fact 
that  the  number  of  "  valuable/'  "  inestimable/'  "  infallible/' 
remedies  grows  with  the  danger  and  incurability  of  the 
disease. 

Those  who  have  seen  in  croup  nothing  but  a  common 
and  always  uniform  affection  of  inflammatory  character, 
have  administered  mercury  in  almost  any  form,  calomel 
in  small  and  large  doses,  the  bichloride,  the  sulphide,  or 
the  alkaline  carbonates  or  bicarbonates,  or  the  sulphide  of 
potassium.  Those  who  saw  in  croup  nothing  but  just  a 
more  or  less  innocent  continuation  of  the  follicular  process 
of  the  mouth  in  a  downward  direction,  relied  on  the  chlorate 
of  potassa  or  soda.  Others  would  rely  on  the  sulphate  of 
copper  in  small  doses,  until  the  two  ends  of  the  intestinal 
tube  were  overflowing  with  it;  others  again,  who  laid  more 
stress  on  the  nervous,  and  especially  spasmodic,  symp- 
toms, would  lead  into  battle  the  salts  of  quinia  and  mor- 
phia, the  narcotic  extracts,  belladonna,  hyoscyamus,  asa- 
foetida,  also  nux;  such  as  had  seen  symptoms  of  infection 
with  croup  would  rely  on  the  muriate  of  iron,  nux,  bromine, 
carbolic  acid.  All  of  them  have  been  considered  infallible 
by  their  godfathers,  and  all  of  them  are  known  to  fail. 

I  do  not  mean  to  make  the  slightest  attempt  at  re- 
futing them,  first,  because  it  requires  more  time  than  I, 
and  more  patience  than  you,  have.  If  a  case  getting  well 
under  a  treatment,  or  in  spite  of  a  treatment,  is  to  give 
credit  to  this  treatment  in  the  eyes  of  the  short-sighted, 
we  cannot  help  it;  we  can  simply  deplore  the  still  pre- 
vailing omnipotence  of  the  "  post  hoc  ergo  propter  hoc." 

One  of  the  indications  was,  treatment  of  the  paralysis 
of  the  vocal  cords.  Can  we  expect  to  remove  this  paralysis, 
say  by  electricity,  which  is  the  most  powerful  antiparalytic 
remedy?  It  appears  not,  for  the  simple  reason  that  this 
paralysis  is  secondary.  It  depends  on  the  oedematous 
soaking  of  the  posterior  crico-arytenoid  muscles  following 
the  oedema  of  the  mucous  membrane  of  the  crico-arytenoid 
folds.  Thus  this  paralysis  cannot  be  influenced  except  by 
removing  this  oedema  from  mucous  membrane  and  muscle. 
This  appears  impossible,  for  instance  by  an  incision,  scari- 

229 


DR.    JACOBFS    WORKS 

fication,  because  it  is  not  local.  You  would  possibly  by  a 
well-directed  scarification  diminish  it,  but  not  remove  it 
Even  local  oedema  glottidis  has  been  known  to  require 
tracheotomy  after  scarifications  had  been  freely  made. 
Moreover,  the  case  is  more  unfavorable  still  for  a  direct 
interference.  The  very  oedema  of  the  mucous  membrane 
(and  sub-mucous  tissue),  of  the  crico-arj^tenoid  folds  giv- 
ing rise  to  the  paralysis  of  the  glottis  is  itself  but  second- 
ary, the  original  cause  being  almost  in  every  case  the 
diphtheritic  and  oedematous  condition  of  the  pharynx.  After 
all  I  have  said,  it  appears  doubtless  that  we  have  to  give 
up  the  idea  of  interfering  with,  or  removing,  the  paralysis 
of  the  glottis  as  met  with  in  croup,  the  nature  of  the 
paralysis  itself  being  as  much  the  cause  of  this  impossibility 
as  the  rapid  course  of  the  morbid  process.  A  mild  case 
may  find  time  to  get  well,  a  serious  one  will  suffocate. 

The  next  indication,  in  case  membranes  are  deposited, 
no  matter  whether  of  the  hard  or  pultaceo'us  character, 
is  to  remove  these  membranous  deposits. 

For  this  purpose  there  have  been  recommended: 

1.  Internal  treatment. 

2.  Mechanical  treatment. 

The  internal  treatment  has  been  mentioned  above;  it 
was  meant  to  have  its  effect  according  to  the  laws  either 
of  physiological  chemistry,  or  the  pathology  of  neuroses. 
The  latter  has  failed.  And  so  is  the  first  sure  to  fail, 
in  your  minds,  if  I  shall  succeed  in  proving  that  the  same 
remedies  which  were  thought  powerful  enough  to  dissolve 
membranes  by  their  presence  in  the  blood,  are  entirely 
powerless  to  dissolve  the  same  membrane  under  your  eye, 
in  your  basin,  in  constant  contact  with  a  stronger  solution 
or  dose  of  the  remedy  than  you  would  dare  to  administer 
internally. 

The  mechanical  or  local  treatment  recommended  is  the 
mechanical  removal  of  the  membranes  within  reach,  with 
forceps,  brushes,  etc. 

Application  of  remedies  expected  to  dissolve  or  soften 
the  membranes,  for  instance  glycerine. 

Application  of  caustics,  and  astringents,  alum,  tannin, 
chloride  of  iron,  mineral  acids,  nitrate  of  silver,  by  means 

230 


Treatment  of  croup 

of  gargles,  direct  local  application  with  the  probang,  the 
forceps,  the  brush,  or  the  pulverizing  apparatus. 

Removal  of  membranes  by  emesis. 

The  gentlemen  are  sufficiently  acquainted  with  the  local 
application  of  nitrate  of  silver  to  the  interior  of  the 
larynx,  inasmuch  as  part  of  the  most  important  literature 
on  the  subject  is  ours.  The  name  of  Horace  Green  is  more 
deserving  of  the  respect  of  Americans  for  his  local  treat- 
ment of  the  air  passages — his  treatment  of  croup  I  should 
not,  however,  include  in  his  great  improvements  in  science 
and  art — than  that  of  Loiseau  of  that  of  the  French.  Now, 
it  has  been  presumed  that  nitrate  of  silver  would  prove 
very  destructive  to  the  laryngeal  false  membrane,  and 
therefore  has  been  widely  recommended.  But  I  wish  to 
remind  you  of  the  results  of  your  local  application  to 
the  pharynx  in  cases  of  simple  diphtheritic  deposits.  Un- 
less you  take,  and  are  allowed,  a  rather  long  time,  to  me- 
chanically tear  up  and  destroy  the  membranes,  with  some 
effort  and  even  violence,  you  will  not  succeed.  The  mem- 
brane is  even  apt  to  shrink  and  harden,  is  not  destroyed,  its 
base  is  intact,  and  a  new  crop  may  follow.  It  is  charac- 
teristic in  nitrate  of  silver  that  its  effect  is  so  very  much 
confined  to  the  exact  point  it  comes  in  contact  with.  In 
a  few  minutes  I  shall  have  to  relate  a  frightful  proof 
of  this  fact. 

Thus  the  very  virtue  of  the  agent  is  a  drawback  where 
you  want  extensive  destruction  and  a  quick  effect.  A  long- 
continued  application  is  out  of  the  question.  I  have  lost 
a  child,  in  whose  larynx  I  operated  with  a  saturated  solution 
of  nitrate  of  silver,  by  instantaneous  death.  And  those 
few  cases  which  I  have  read  of,  and  one  or  two  cases  that 
friends  have  reported  in  medical  societies,  cases  in  which 
the  probang  with  a  solution  of  nitrate  of  silver  proved 
effective,  prove,  in  my  opinion,  nothing  for  the  nitrate  of 
silver,  but  everything  as  far  as  it  goes  for  the  moist  pro- 
bang  with  its  direct  mechanical  effect,  and  its  indirect 
effect  in   producing  coughing,  etc. 

We  ought  not  to  forget  that  the  local  treatment  of 
croupous  or  diphtheritic  membranes  in  the  pharynx  when 
desirable,  is  a  great  deal  easier  than  in  the  larynx.     The 

231 


DR.    JACOBI'S    WORKS 

facility  is  greater,  and  the  organ  neither  so  vital  nor  so 
vulnerable.  And  what  applications  to  membranes  may  be 
expected  to  do,  will  be  seen  by  the  following  results  of 
direct  experiments,  part  of  which  I  have  had  frequent 
chances  to  repeat: 

Lime  water  requires  thirty  to  fifty  hours  to  disintegrate 
false  membranes,  and  three  days  or  more  to  entirely  dis- 
solve them.  It  requires  from  four  to  ten  hours  to  thor- 
oughly  liquefy   the   soft   pultaceous   diphtheritic    deposits. 

Hydrates  of  potassa  and  of  soda,  1 :  500,  act  more  slowly 
than  lime  water. 

Permanganate  of  potassium,  1:120,  disintegrates  false 
membranes  in  its  outer  parts,  while  the  interior  remains 
hard  and  solid,  in  ten  hours. 

Carbonate  of  lithia  and  carbonate  of  soda,  1:  100-150, 
had  the  same  effect  in  the  same  time.  About  the  same 
time  is  required  by  the  constant  effect  of  chlorinated 
water. 

Nitrate  of  soda,  1 :  200-300,  has  no  effect  on  membranes. 
Iodine,  the  officinal  tincture,  or  a  solution  of  1 :  200, 
shrinks  and  hardens  them. 

Nitric  acid,  1 :  50,  has  the  same  effect.  So  has  acetic 
acid,  except  on  the  soft  diphtheritic  masses,  which  get  dis- 
integrated. 

The  only  agent  which  dissolves  membranes  soon,  but 
one  which  is  hardly  fit  for  use  for  obvious  reasons,  is 
ammonia. 

Carbolic  acid,  applied  to  a  membrane  or  a  pultaceous 
diphtheritic  deposit,  shrinks  it  in  a  short  time,  making 
it  removable  to  a  high  degree.  The  difficulty,  however, 
of  applying  it  to  the  larynx  and  bringing  it  into  contact 
with  a  sufficiently  large  surface  is  very  great  indeed. 
To  normal  tissue  it  is  not  without  danger.  Thus  I  am 
not  prepared  to  say  what  it  may  be  made  to  do  in  croup 
of  the  larynx,  while  I  am  pleased  with  its  local  effects 
in  the  same  affection  of  the  fauces.  To  act  quickly  it 
must  be  applied  very  little,  if  at  all  diluted,  and  requires 
an  experienced  hand. 

Subsulphate  of  iron  and  sesquichloride  of  iron  ait,  al- 
though,  perhaps,   not   so   vigorously,   similarly   to   carbolic 

232 


TREATMENT    OF    CROUP 

acid.  They  have^  however,  the  disagreeable  property  of 
shrinking  and  coagulating,  and  as  it  were  accumulating 
in  a  bulk,  whatever  of  albuminous  substances  is  in  reach. 
Thus  mucus  and  blood  are  coagulated  and  form  with  the 
iron  a  firm,  hardly  removable  mass,  which  may  interfere 
with  both  deglutition  and  respiration,  and  give  rise  to  great 
annoyance.  And  another  one  which  it  will  be  worth  while 
to  experiment  with  is  bromine.  One  grain  of  bromine, 
one  grain  of  bromide  of  potassium,  in  three  hundred  and 
sixty  grains  of  water,  will  liquefy  a  membrane  in  a  few 
hours. 

Thus  it  appears  that  unless  bromine  will  prove  effective, 
it  is  not  worth  while  to  try  the  effect  of  anything  but 
lime  or  carbolic  acid.  This  much  is  sure,  that  it  will  prove 
effective,  to  a  certain  extent,  where  it  can  be  retained  in 
contact  with  diphtheritic  masses.  Thus  I  am  pleased  with 
their  effect  in  nasal  diphtherite,  where  the  deposits  are 
frequently  softer,  thinner,  half  solid  only.  Frequent,  say 
hourly,  injections  of  lime  water  into  the  nose  have  evi- 
dently rendered  me  good  service;  how  far,  however,  this 
effect  will  show  itself  in  the  larynx,  where  the  application 
cannot  be  made  so  thoroughly  nor  so  frequently,  or 
how  far  the  few  reports  of  a  cure  by  the  inhalation  of 
pulverized  lime  water  can  be  trusted,  remains  to  be  seen. 
At  all  events,  the  scarcity  of  the  reported  successes — and 
we  may  be  sure  that  real  or  apparent  successes  in  the 
treatment  of  croup  will  not  be  concealed — is  in  exact  pro- 
portion to  the  insolubility  of  false  membranes,  and  to  the 
rapid  course   and  usual   fatal  termination   of  the   disease. 

Concerning  the  removal  of  membranes  by  emesis,  we 
know  that  emetics  stand  almost  foremost  in  the  list  of 
the  remedies  recommended  in  every  form  of  croup,  for 
their  revulsive  and  diaphoretic,  and  their  mechanical  ef- 
fect. Of  the  first  I  have  no  idea  unless  it  means  the  sec- 
ond. My  opinion  of  this,  the  diaphoretic  effect,  and  the 
necessity  or  advisability  of  diaphorosis,  I  have  briefly 
stated.  Thus,  no  efffect  but  the  mechanical  one  appears 
reliable;  and  it  is  reliable  in  some  cases.  When  the 
dyspnoea  depends  on  the  collection  and  accumulation  of 
mucus  in  the  larynx,  or  when  mucus  is  one  of  the  factors 

233 


DK.    JACOBI'S    WOHKS 

only,  it  will  alleviate  the  symptoms,  and  may  be  resorted 
to  and  repeated.  When  the  obstruction  is  membranous,  it 
will  be  of  less  importance,  inasmuch  as  the  membranes  are 
mostly  closely  attached  in  the  beginning,  that  is,  for  days, 
to  the  larynx,  especially  in  those  places  which,  like  the  fos- 
sae Morgagni,  are  less  exposed  to  the  current  of  air  from 
the  lungs.  But  the  eifect  of  the  emetics  is  greater  than 
that  of  the  most  severe  spell  of  coughing,  because  of  the 
dilatation  of  the  glottis  which  takes  place  during  vomiting. 
In  this  dilatation  a  larger  portion  of  the  larynx  is  exposed 
to  the  current  of  air  emanating  from  the  lungs  than  in 
coughing.  Thus  there  is  hardly  an  objection  to  trying  the 
effect  of  an  emetic  in  a  case  of  membranous  obstruction 
of  the  larynx,  which  will  best  be  diagnosticated  by  the 
expiration  being  impeded  like  inspiration,  with  a  view  of 
detaching  it  from  the  walls  of  the  larynx;  especially  is  it 
indicated  when  membranes  are  partially  loosened.  This 
condition  is  sometimes  diagnosticated  amidst  the  most  ur- 
gent dyspnoea  by  a  peculiar  loud,  clashing,  flapping  sound, 
particularly  in  expiration.  Whenever  relief  is  obtained,  it 
ought  to  be  repeated  from  time  to  time,  not  otherwise. 
When  the  symptoms  of  general  paralysis  from  deficient 
decarbonization  of  the  blood  are  on  the  increase,  reac- 
tion will  cease,  and  emetics  will  withhold  their  effect, 
even  at  a  period  where  spontaneous  vomiting  may  still 
take  place.  When  such  is  the  case  the  most  powerful  of 
all  irritants,  cold  effusions  to  the  head,  or  neck,  or  the  pit 
of  the  stomach,  may  still  rouse  the  reaction  of  the  ob- 
longated  spine  and  the  pneumogastric  nerves. 

Of  the  remedies  which  ought  to  be  resorted  to  I  have 
spoken  already.  I  prefer  the  sulph.  cupri  to  any  of  the 
rest.  The  mode  of  their  producing  emesis  is  the  same, 
and  as  emesis  only  is  required,  the  most  reliable  medica- 
ment ought  to  be  selected. 

The  indication  of  cutting  short  the  process  of  obstruc- 
tion, to  interrupt  the  course  of  the  disease,  has  appeared 
to  many  to  require  the  use  of  diaphoretics,  depletion,  vesica- 
tories:,  warm  applications,  or  cold  applications. 

Diaphoretics. — Their  effect  is  perceptible  in  cases  of 
simple   catarrhal  hyperaemia  only.      The  dilatation   of  the 

234 


TREATMENT    OF    CROUP 

capillaries  of  the  surface  is  apt  to  empty  internal  blood- 
vessels. Thus  it  is  rational  to  try  diaphoretics  in  cases 
of  catarrh,  or  wherever  for  a  little  while  the  diagnosis 
between  catarrh  and  croup  is  doubtful.  While,  however, 
it  would  be  worse  than  unwise  to  expose  the  body  of  the 
patient  to  cold  air,  we  ought  not  to  forget  that  it  is  un- 
physiological  and  worse  than  wasting  time  to  expect  the 
reduction  of  a  nutritive  disorder  of  such  an  extent  from 
the  administration  of  internal  diaphoretics,  or  diaphoretic 
external  treatment. 

Local  depletion  has  frequently  been  recommended. 
Leeches  were  to  be  applied  to  the  throat,  to  the  manu- 
brium sterni.  The  same  can  be  said  of  them  as  of  dia- 
phoretics. They  may  not  be  very  injurious  in  catarrh; 
theoretically  they  may  even  be  justified,  although  the 
saine  end  is  better  obtained  by  more  innocent  remedies; 
they  may  not  hurt  robust  and  vigorous  children  whose 
strength  is  not  so  easily  consumed.  But  again,  inflamma- 
tion and  hyperaemia  do  not  always  coincide,  and  exuda- 
tion is  not  prevented  by  leeching.  To  the  contrary,  the 
well-known  fact  that  the  proportion  of  fibrin  in  the  blood 
increases  with  every  depletion,  ought  to  make  us  very 
cautious  indeed.  Moreover,  the  danger  of  local  or  general 
depletion  in  diphtheria  ought  to  be  too  well  understood  to 
be  underestimated.  For  nearly  ten  years,  in  this  city  and 
over  the  world,  diphtheria  has  been  prevalent,  with  all  its 
local  destructiveness  and  its  constitutional  poison ;  the  large 
majority  of  cases  of  croup  have  been  of  a  diphtheritic 
character.  The  result  of  depletion  in  such  cases  is  but 
too  often  the  rapid  increase  of  exhaustion,  and  the  forma- 
tion of  diphtheritic  deposits  on  the  sore  surface.  Thus 
I  consider  the  use  of  depletion  in  croup  as  excusable  in 
but  few  cases,  although  hardly  ever  indicated;  in  the  ma- 
jority of  cases  it  is  dangerous. 

What  I  have  said  of  depletion  is  also  valid  for  vesica- 
tories.  It  is  characteristic  for  diphtheria  that  not  only 
mucous  membranes,  but  the  cutis  too,  wherever  it  is  de- 
nuded of  its  epidermis,  will  be  readily  covered  with  mem- 
branes or  pultaceous  deposits.  Thus  eczematous  or  im- 
petiginous sores  will  undergo  this  change;  and  those  who 

235 


DR.    JACOBI'S    WORKS 

have  performed  tracheotomy  or  any  other  operation  in  a 
diphtheritic  individual^  or  during  the  prevalence  of  an 
epidemic,  have  had  sufficient  reason  to  be  shocked  at  diph- 
theria exhibiting  its  eruption  within  twelve  or  twenty-four 
hours.  I  have  seen  dozens  of  tonsils  removed  from  ap- 
parently healthy  individuals  in  such  seasons,  covered  with 
diphtheritic  deposits  within  a  day,  and  remember  to  have 
lost  a  case  of  resection  of  the  head  of  the  femur  from  the 
same  cause.  Thus,  beware  of  vesicatories.  Their  usual 
result  is  not  a  relief,  but  diphtheritic  covering  or  disin- 
tegration of  the  affected  part,  and  frequently  collateral 
swelling.  I  do  not  assert  too  much  when  I  say  that  the 
only  effect  I  have  ever  seen  from  their  use  has  been  very 
unfavorable. 

Both  warm  and  cold  applications  have  been  made  to 
the  larynx,  externally,  for  the  purpose  of  alleviating  the 
symptoms,  or  interrupting  the  progress  of  the  disease. 
Can  we  expect  an  effect,  by  either  of  the  two,  on  the 
formed  and  deposited  membrane?  No.  Thus  we  cannot, 
in  fact,  expect  to  influence  the  fully  developed  disease 
by  either.  Or  on  the  collateral  oedema  and  consecutive 
paralysis  of  the  vocal  cords?  Exactly  the  same  must  be 
true.  Now,  in  inflammatory  and  exudative  processes  in 
other  organs  and  regions  we  use  both  warm  and  cold 
applications,  but  it  appears  to  me  for  different  indications, 
and  for  different  purposes.  There  is  no  doubt  that  warm 
poultices  in  a  certain  advanced  stage  of  peritonitis  or 
pneumonia  will  do  a  great  deal  to  promote  the  absorption 
of  exudation,  and  the  comfort  of  the  patient;  but  absorp- 
tion we  do  not  expect  in  croup  of  the  larynx,  and  com- 
fort there  is  none.  But  wherever  we  do  have  a  conges- 
tive disease,  an  inflammation  based  upon  hyperaemia,  a 
dilated  condition  of  the  blood-vessels,  cold  applications, 
when  the  parts  are  within  easy  reach,  are  the  only  reason- 
able means  to  fall  back  upon.  If  this  is  true  of  enteritis, 
peritonitis,  or  pneumonia,  it  is  so  much  the  more  so  in 
affections  of  the  larynx  with  its  easy  access  and  its  close 
proximity  to  the  skin.  The  only  thing  I  should  not  like 
to  dispense  with  in  the  treatment  of  croup,  is,  therefore, 
ice,  which,  if  anything,  is  the  most  simple,  unexhausting, 

236 


TREATMENT    OF    CROUP 

and  direct  remedy  possible.  There  is,  in  fact,  no  period 
of  croup  in  which  it  has  any  contraindication,  although  its 
effect  is  only  to  be  considered  as  preventive  of  exudation. 

Of  all  the  remedies  as  used  in  croup,  we  cannot  say 
anything  better  than  that  most  of  them  are  useless,  some 
injurious.  From  what  I  have  stated  as  my  experience, 
and  that  of  hundreds  of  better  men,  and  from  what  I 
know  to  be  the  experience  of  the  large  majority  of  the 
gentlemen  present,  the  great  mortality  statistics  of  croup 
are  but  too  well  confirmed.  Statements  of  such  epidemics 
in  which  seventy  or  seventy-five  per  cent,  of  all  the  cases 
of  true  croup  have  died,  are  highly  favorable,  such  with 
ninety   or  ninety-five   per   cent,   not   at   all   uncommon. 

Thus,  very  little  reliance  can  be  placed  on  the  judg- 
ment and  the  diagnostic  powers  of  such  as  save  a  large 
majority  of  their  cases,  or  who  rely  on  infallible  pet 
remedies. 

As  a  general  rule,  I  like  the  bowels  of  the  patient  moved 
by  an  injection  to  give  his  abdominal  muscles  and  dia- 
phragm as  fair  play  as  possible.  I  apply  ice  in  com- 
fortable bags  to  his  larynx.  I  now  and  then,  according  to 
the  condition  of  the  fauces,  try  sesquichloride  of  iron,  or 
carbolic  acid,  to  the  visible  membranes.  I  have  not  seen 
yet  that  I  have  succeeded  in  directly  influencing  the  laryn- 
geal deposits.  When  the  diagnosis  is  any  way  doubtful, 
I  allow  a  mixture  of  chlorate  of  soda  or  potassa  with 
chloride  of  ammonia,  frequently  repeated,  say  one  to  three 
drachms  of  the  former  to  one-half  to  one  drachm  of  the 
latter  per  day.  When  attacks  of  dyspnoea  or  suffocation 
come,  an  occasional  emetic.  When  with  all  this  the  symp- 
toms become  graver,  pulse  more  frequent,  or  even  irreg- 
ular, and  all  the  other  symptoms  enumerated  before  show 
themselves,  I  cannot  but  confess  that  I  have  no  more 
power  over  the  process,  and  that  it  will,  as  far  as  human 
experience  and  foresight  go,  destroy  the  patient,  unless 
you  find  the  means  of  supplying  the  lungs  with  oxygen. 

For  this  purpose  the  development  of  oxygen  in  the  pa- 
tient's room  has  been  resorted  to.  How  much  oxygen 
they  do  obtain  by  such  process,  is  uncertain;  it  is  still 
more   improbable    that   the   patients,   in    the    condition   in 

237 


DR.    JACOBI'S    WORKS 

which  they  are,  can  be  made  to  inhale  voluntarily.  More- 
over, pure  oxygen  is  not  fit  for  respiration,  on  the  con- 
trary, it  causes  dyspnoea  in  the  healthy;  the  mixture  in 
which  oxygen  is  in  the  atmosphere  appears  to  be  the  only 
proper  food  for  the  blood,  and  alone  capable  of  keeping 
up  the  diffusion  of  gases  through  the  walls  of  the  pul- 
monary   capillaries. 

For  the  same  purpose  Bouchut  invented  and  described 
his  "  tubage."  He  introduced,  so  he  said,  tubes  between 
the  vocal  cords,  through  which  the  croupous  children  would 
immediately  breathe  quietly  and  sufficiently.  Now,  in  a 
larynx  filled  with  membranous  or  other  diphtheritic  de- 
posits, this  is  a  plain  impossibility.  Only  in  cases  of  par- 
alysis of  the  vocal  cords  such  a  proceeding  could  be 
thought  of.  Whether  it  can  be  done  or  endured,  I  do 
not  know.  But  I  do  know  that  Bouchut  has  not  succeeded 
himself,  inasmuch  as  he  asserts  that  the  children  into 
whose  glottides  he  introduced  his  tubes,  expressed  to  him 
their  gratitude,  by  words,  immediately  after.  When  re- 
porting on  this  "  tubage  "  of  Bouchut's,  Trousseau  al- 
ready stated  that  the  hitherto  known  laws  of  physiology 
would  forbid  a  child  to  speak  with  the  vocal  cords  held 
aside,  and  steadied  by  a  solid  tube  in  the  rima  glot- 
tidis. 

For  this  purpose,  finally,  we  perform  tracheotomy;  that 
is,  we  afford  the  air  access  to  the  lungs  below  the  ob- 
structed point.  Thus  tracheotomy  is  not  a  cure  for  croup, 
it  is  simply  a  means  to  keep  the  patient  from  suffocating 
until  the  process  above  has  completed  its  course.  As  soon 
as  the  larynx  will  be  pervious  again,  you  expect  to  close 
your  artificial  opening.  Thus  tracheotomy  appears  on  a 
level,  but  more  favorable  than  these,  with  paracentesis 
of  the  bladder,  operation  for  artificial  anus,  or  thoraco- 
centesis for  acute  copious  effusion.  Thus  there  ought  to 
be  no  contraindication  when  the  prominent  symptom  is 
dyspnoea,  and  suffocation.  I  cannot  imagine  any  compli- 
cation of  croup  that  would  prevent  me  from  opening  the 
trachea  when  the  child  is  dying  of  suffocation.  This  is 
so  plain  to  my  understanding  that  I  should  consider  it 
even  a  cruelty  to  refuse  tracheotomy  when  I  knew  before- 

238 


TREATMENT    OF    CROUP 

hand  that  the  child  was  surely  going  to  die.  Whoever 
has  seen  children  die  of  croup,  fully  conscious,  gasping, 
raving  for  air  until  they  are  slowly  strangled  in  your 
arms,  under  your  eyes,  will  at  least  bless  a  proceeding, 
the  consequence  of  which  will  in  most  cases  be  an  easier 
death;  with  the  exception  of  those  in  which  solid  mem- 
branes will,  after  the  operation,  migrate  down  into  the 
smallest   ramifications   of  the   bronchial   tubes. 

Nor  do  I  acknowledge  that  tender  age,  the  age  under 
two  years,  ought  to  be  held  as  contraindication  to  the 
performance  of  the  operation. 

Now,  it  is  a  fact  that  the  results  of  the  operation  at 
this  age  are  much  less  favorable  than  at  a  more  advanced 
period.  All  and  every  statistical  record  yields  the  same 
evidence.  But  lately,  Gtiterbock  has  published  one  hun- 
dred cases  of  tracheotomy  for  croup,  one  of  which  was 
under  a  year,  one  under  two  years,  both  terminating 
fatally.  As  far  as  the  rest  is  concerned  of  those  operated 
upon,  between  the  second  and  third  year  the  percentage  of 
recovery  was  33  1-3;  between  the  third  and  fourth  year, 
40  per  cent.;  between  the  fourth  and  fifth  years,  38  8-13 
per  cent. ;  between  the  fifth  and  sixth  year,  44  4-9  per 
cent. ;  between  the  sixth  and  seventh  year,  44  4-9  per  cent. ; 
between  the  seventh  and  eighth  year,  14  2-7  per  cent.; 
between  the  eighth  and  ninth  year,  25  per  cent. 

Theoretically,  there  is  no  reason  for  tender  age  being 
an  excuse  why  suffocating  infants  should  be  left  to  a 
sure  death.  If,  however,  clinical  experience  would  sus- 
tain the  contraindication  as  such,  we  might  be  satisfied  with 
leaving  them  to  their  fate.  But  fortunately  the  case  is 
not  so  bad  after  all.  For  there  are  a  number  of  cases 
on  record  in  which  tracheotomy  performed  on  very  young 
children  proved  successful.  I  will  not  urge  the  case  of 
Scoutetten,  erroneously  attributed  to  Sedillot  lately,  who 
operated  on  an  infant  of  six  weeks,  as  it  has  been  de-^ 
clared  to  have  been  a  case  of  so-called  pseudo-croup;  al-^ 
though,  even  if  this  was  so,  the  advisability  and  possibility 
of  the  operation  was  clearly  proved  by  this  very  case. 
But  the  cases  of  Baizeau,  in  an  infant  of  ten  months,  and 
m  another  pf  fifteen  months;  the  case  of  Isambert,  six- 

239 


DR.    JACOBI'S    WORKS 

teen  months;  Archambault,  thirteen  and  eighteen  months; 
Royer,  nineteen  months;  Vigla,  seventeen  months;  Potain, 
eighteen  months ;  Moutard-Martin,  eighteen  months ;  Trous- 
seau, thirteen  months;  Barthez,  thirteen  and  seven  months, 
prove  the  very  fact  that  the  general  indication  for  trache- 
otomy, namely,  obstructive  disease  of  the  larynx,  remains 
valid. 

Dr.  Krackowizer's  earliest  case  of  recovery,  in  this 
city,  was  not  two  years  old.  He  removed  the  tube  on  the 
child's  third  birthday,  but  was  compelled  to  introduce  it 
again  for  a  few  days. 

The  result  of  my  own  cases  of  tracheotomy  is  as  fol- 
lows :  I  have  operated  on  sixty-eight  children,  sixty-seven 
times  for  croup,  once  for  a  foreign  body  contained  in  the 
larynx.  The  case  was  that  of  an  infant  of  eleven  months, 
who  had  a  flat  bone  seven  lines  long  and  one  to  four  lines 
wide  lodged  in  the  larynx  while  being  fed.  The  danger 
appearing  imminent,  dyspnoea  growing  from  minute  to  min- 
ute and  resulting  in  a  general  cyanotic  hue  of  the  face, 
and  emetics  proving  useless,  help  was  immediately  sought 
for  and  the  operation  of  tracheotomy  performed  about  two 
hours  after  the  accident.  The  foreign  body  was  dislodged 
from  below  upward  through  the  tracheal  opening  with 
great  difficulty;  after  it  had  been  removed  the  dyspnoea 
was  not  entirely  relieved,  and  the  child  did  not  breathe 
normally  except  through  the  tube  only.  It  appeared  that, 
although  there  was  no  longer  a  foreign  body  inside  the 
larynx,  it  had  during  its  stay  there  worked  changes  re- 
sulting in  obstruction.  It  was,  therefore,  impossible  to 
remove  the  tube,  symptoms  of  laryngitis  showed  them- 
selves after  a  few  days,  high  fever  set  in,  and  the  infant 
died  on  the  eleventh  day  after  the  operation,  of  traumatic 
laryngitis.  The  post-mortem  appearances  were:  intense 
catarrhal  injection,  intermingled  with  an  occasional  ec- 
chymosis  of  the  epiglottis,  considerable  swelling  of  the 
entire  mucous  membrane  of  the  larynx,  and  sloughing  of 
the  fossae  Morgagni  and  part  of  the  vocal  cords. 

Of  the  sixty-seven  cases  of  tracheotomy  for  croup, 
thirty-eight  were  made  on  boys,  twenty-nine  on  girls.  Of 
the    sixty-seven,    thirteen    recovered;    of    the    thirty-eight, 

240 


TREATMENT    OF    CROUP 

eight  recovered^  of  the  twenty-nine,  five  recovered.  Thus, 
the  total  percentage  of  recoveries  is  about  nineteen  and  a 
half. 

The  percentage  looks  a  little  more  unfavorable  than  it 
really  is.  Eor  there  are  five  cases,  boys  of  two,  two,  two, 
and  five  years,  and  a  girl  of  nineteen  months,  who  swell 
the  lists  of  my  mortality  unnecessarily.  One  boy  died  in 
my  presence  while  I  was  preparing  the  table  and  instru- 
ments. A  single  incision  opened  the  trachea  of  the  child 
hastily  thrown  upon  the  table  and  pulled  over  its  edge, 
but  too  late.  In  another  case  I  was  induced  to  operate, 
although  I  found  the  little  girl  dying,  by  the  attending 
physician,  who  had  been  patiently  extorting  the  permis- 
sion of  the  parents  and  waiting  for  the  surgeon  for  many 
hours.  The  other  three  cases  were  of  a  similar  description; 
for  hours  no  emetic  had  resulted  in  emptying  the  stomach, 
no  external  irritation  yielded  a  reaction,  and  if  I  had  had 
the  control  of  the  case  I  should  not  have  performed  the 
operation.  At  all  events,  these  five  operations  were  made 
on  individuals  who  either  were  dead  or  dying,  and  in 
whom  the  indication  for  an  operation  had  long  passed 
by.  Thus  I  am  justified,  I  believe,  in  saying  that  there 
are  thirteen  recoveries,  namely,  twenty-one  per  cent.,  out 
of  sixty-two  operations.  You  will,  besides,  please  not  for- 
get the  fact  that  I  have  frequently  had  to  wait  for  the 
permission  to  operate  for  hours  beyond  the  normal  indica- 
tion, and  that  this  very  delay  has  in  many  cases  impaired 
the  chances  of  the  patients.  This  complaint  of  mine  is 
as  easily  understood  as  it  is  expressed  by  all  of  those 
surgeons  who  have  operated  in  a  large  number  of  cases, 
and  in  other  than  hospital  practice.  But  the  blame  is  not 
confined  to  the  attendants  and  relatives  only,  it  has  some- 
times been  myself  who  is  to  be  blamed  for  delay,  as  I 
am  positive  to  have  lost  good  opportunities  by  procrastina- 
tion. Especially  in  those  cases  which  take  a  very  rapid 
course,  such  procrastination  has  occurred;  it  is  but  too 
natural,  now  and  then,  to  hesitate  in  spite  of  your  exact 
knowledge  of  the  indication,  before  you  operate  on  a  child 
who  a  few  hours  before  was  perhaps  the  picture  of 
health.     And  still,  nobody  would  think  of  hesitating  when 

241 


DR.    JACOBI'S    WORKS 

a  foreign  body  was  located  in  the  larynx,  though  I  re- 
luctantly confess  that  I  believe  I  have  lost  lives  by  losing 
time.  A  case  of  this  description  occurred  but  lately.  A 
boy  of  a  little  more  than  two  years  was  taken  with  hoarse- 
ness and  moderate  fever,  and  a  croupy  cough.  The  mes- 
sage did  not  reach  me  before  the  following  morning,  when 
I  paid  my  first  visit  at  10  a.  m.  Hardly  any  deposit  on 
a  (the  left)  tonsil,  great  dyspnoea,  but  voice  not  gone, 
the  muscles  of  the  thorax  in  thorough  exertion,  perspira- 
tion, pulse  of  140.  The  mother  had  during  the  night  ad- 
ministered chlorate  of  soda,  and  applied  ice  water  to  the 
throat.  Treatment  continued,  with  an  occasional  emetic, 
until  I  should  call  in  the  afternoon.  Visit  at  5  p.  m. 
More  dyspnoea  and  perspiration,  dyspnoea  constant,  cya- 
notic hue  of  lips  and  nose,  pulse  150  to  l60,  irregular.  Still, 
I  try  the  effect  of  an  emetic;  it  takes  effect,  but  gives  no 
relief.  Then  I  call  on  Dr.  Chamberlain  for  assistance  in 
the  operation,  which  is  performed  at  7  p.  m.  The  relief 
afforded  by  it  is  striking,  but  below  my  expectation ;  three- 
quarters  of  an  hour  after  the  operation  the  respiration  is 
rougher,  harsher  than  normal,  36  to  40,  pulse  124  to 
128,  the  patient  tolerably  quiet,  but  spells  of  restlessness, 
which,  however,  do  not  last  very  long.  At  10  p.  m.  an 
occasional  crepitant  rale,  44  to  48  respirations,  150  pul- 
sations, heat  of  skin  increased,  no  dull  percussion  sound. 
I  fear  a  beginning  broncho-pneumonia,  and  state  my  un- 
easiness concerning  the  termination  of  the  case  to  Dr. 
Chamberlain,  who  kindly  accompanied  me.  At  3^  a.  m. 
I  was  sent  for,  only  to  learn  that  the  child  had  died  soon 
after  the  messenger  went  for  me.  The  post-mortem  exami- 
nation revealed,  besides  the  complete  membranous  obstruc- 
tion of  the  larynx,  a  few  thin  and  small  membranes  cor- 
responding with  the  first  five  or  six  cartilages  of  the  tra- 
chea, intense  injection  and  ecchymotic  discoloration  of  the 
lining  membrane  of  the  trachea  and  bronchi  with  their 
ramifications,  a  general  and  intense  oedema  of  the  lungs; 
no  pneumonia,  no  hemorrhage,  no  collapse  of  the  lung. 
Those  who  are  conversant  with  the  mechanical  influence 
of  the  rarefaction  of  the  air  inside  the  lungs,  and  the 
disproportion   between   the    tension    of   blood   in    the   ves- 

O.iO 


TREATMENT    OF    CROUP 

sels  and  the  diminished  atmospheric  pressure  on  their 
walls  from  outside,  will  be  apt  to  explain  the  post-mortem 
appearance  and  the  mode  of  dying.  It  has  been  the  only 
case  of  uncomplicated,  fatal  pulmonary  cedema  after  croup 
and  tracheotomy  which  I  have  seen,  and  there  are  but  few 
such  cases  on  record.  The  tendency  is  much  more  to  the 
development  of  an  exudative  than  an  effusive  process,  and 
while  broncho-pneumonia  is  a  frequent  occurrence,  uncom- 
plicated pulmonary  oedema  is  as  rare  as  it  is  instructive. 
Of  my  patients  one  was  at  the  age  of  1  year  1  month; 
one,  1  year  2  months ;  one,  1  year  7  months ;  one,  1  year 
10  months;  five,  2  to  2^  years;  nine,  2^  to  3  years;  six- 
teen, 3  to  4  years,  twenty-three,  4  to  5  years ;  seven,  5  to 

6  years;  two,  7  to  8  years;  and  one   10  years. 
Recoveries  took  place: 

1  at  the  age  of  2J  to  3  years,  1  out  of  5  operations,=20  per  cent. 
3  "  3     "4       "       1       "      16  "  =19 

7  "  4     "    5       "       1       "      33  "  =30        " 

2  •  "  5     "    6       "       1       "        7  "  =28  4-7" 

The  after-treatment  in  some  of  these  cases  was  pro- 
tracted, and  therefore  the  tube  had  to  remain  in  some  a 
pretty  long  time.  It  was  removed  in  two  cases  on  the  17th 
day,  one  on  the  18th,  one  on  the  20th,  one  on  the  27th, 
one  on  the  29th,  one  on  the  30th,  two  on  the  35th,  one 
on  the  42d,  one  on  the  44th,  one  on  the  46th,  and  one  on 
the  54th  day. 

The  cause  of  the  long  duration  of  the  after-treatment 
was  in  four  cases  of  a  peculiar  nature.  It  was  found  that 
in  the  second  week  after  the  operation,  the  larynx  hav- 
ing expelled  the  macerated  membranes,  would  resume  its 
functions,  and  the  patient  breathe  normally  through  the  tube 
and  its  upper  fenestra,  and  the  larynx,  the  anterior  open- 
ing of  the  tube  having  been  closed  by  a  cork.  But  the 
removal  of  the  tube  from  the  trachea  gave  rise  to  instan- 
taneous attacks  of  dyspncEa  and  suffocation,  which  were 
instantly  removed  again  by  the  replacing  of  the  tube. 
This  occurrence  would  take  place  so  regularly  that  the 
patients  would  not  admit  the  removal  of  the  tube   after- 

243 


DR.    JACOBI'S    WORKS 

ward.  The  cause  of  this  strange  and  unsatisfactory  oc- 
currence was  found  to  be  the  presence  of  polypoid  ex- 
crescences, sometimes  numerous,  of  the  size  of  a  pin's  head 
to  that  of  a  pea  and  more,  originating  on  the  margin  of 
the  tracheal  wound,  in  one  case  on  the  lower  portion  of 
the  sore  larynx  itself.  It  required  a  great  many  appli- 
cations of  nitrate  of  silver,  or  subsulphate  of  iron,  to  de- 
stroy them;  their  disappearance  would  instantly  relieve 
the  symptoms  and  allow  of  the  final  removal  of  the  tube 
from  the  trachea.  Such  is  the  case  of  the  boy  D'Echauf- 
four,  a  patient  of  Dr.  Hoeber's,  for  whom  I  performed  the 
operation,  at  No.  67  Sixth  Street,  whose  final  recovery 
was  long  deferred  by  such  new-formed  granulations,  and 
who  is  still  said  to  suffer  now  and  then  from  sudden  at- 
tacks of  dyspncEa,  which  (although  I  have  not  seen  the 
child  for  some  time)  may  still  depend  on  the  presence 
of  small  polypous  excrescences,  giving  rise  to  obstruction 
or  spasmodic  contractions,  when  forced  inspirations  are 
taking  place. 

Not  all  of  my  operations  were  made  on  uncomplicated 
cases  of  laryngeal  obstruction.  In  two,  bronchitis  had  been 
diagnosticated  in  the  incipient  stages  of  croup,  and  almost 
all  the  cases,  from  1859  to  1867,  were  complicated  with 
local  and  general  symptoms  of  diphtheria.  Seldom  have 
I  operated  on  a  case,  without  fever  attending  it  from  the 
beginning;  seldom  without  the  presence  of  swelling  of  the 
adjoining  lymphatic  glands.  Those  who  have  watched  the 
prevalence  of  local  diphtheria  and  general  diphtheria  in 
this  city  from  1858  up  to  this  day,  will  feel  satisfied  that 
my  statement  is  not  exaggerated. 

Now,  while  I  admit  that  with  symptoms  of  general  diph- 
theria complicating  a  case  of  laryngeal  diphtherite  called 
membranous  croup,  the  prognosis  of  the  operation  becomes 
more  doubtful,  I  lay  stress  on  the  very  same  fact  for  the 
reason,  that  even  in  such  cases,  the  only  indication  for  the 
operation  rests  in  the  local  obstruction.  For  it  is  easily 
understood,  that  while  general  diphtheritic  poisoning  with 
insufficient  obstruction  does  not  indicate  tracheotomy;  it 
is  just  as  plain  common  sense  that  suffocation  from  ob- 
struction of  the   larynx   complicated  with  a  constitutional 

244 


TREATMENT    OF    CROUP 

affection,  requires  the  only  possible  relief  just  as  urgently 
as  suffocation  from  obstruction  of  the  larynx  without  such 
a  complication.  Seeing  a  person  suspended  by  the  neck 
and  being  strangled,  we  should  hardly  investigate  into  the 
propriety  of  cutting  the  rope  from  the  point  of  view  that 
the  sufferer  might  be  or  is  affected  at  the  same  time,  with 
tuberculosis,  carcinosis,  or  diabetes. 

Still,  there  are  other  complications  of  croup  which  in 
tlie  opinion  of  many  authors  have  contraindicated  the  op- 
eration. Among  these  is  bronchitis,  and  broncho-pneu- 
monia, or  other  serious  diseases.  But  among  the  number 
of  my  recoveries  is  the  boy  Rinaldo,  of  Qit  Catherine 
Street,  who  had  been  suffering  from  bronchitis  before  the 
membranous  obstruction  of  the  larynx,  resulting  in  im- 
minent danger  of  life,  with  the  usual  symptoms,  required 
tracheotomy,  who  developed  bilateral  pneumonia  after  the 
operation,  and  still  got  well;  and  the  boy  D'Echauffour, 
of  67  Sixth  Street,  who  was  taken  with  scarlatina,  three 
days  after  the  operation,  and  also  recovered.  I  mention 
these  facts  to  show  that  no  regard  and  no  prejudice  ought 
to  detain  us  from  opening  a  new  base  of  supply,  when  the 
original,  normal  one  is  cut  off. 

Death  followed  the  operation,  out  of  the  54  fatal  cases, 
within  62  hours,  in  four  cases;  within  1  day  in  seven;  on 
the  2d  day  in  three;  the  3d  in  eleven;  the  4th  in  ten;  the 
5th  in  seven;  the  6th  in  four;  the  7th  in  one;  the  9th  in 
one;   and  the   13th  in  one. 

The  causes  of  death  were  the  following: 

Suffocation  before  the  operation  was  finished,  1.  It  was 
the  case  of  a  girl  of  five  years,  hearty  and  robust;  no 
difficulty  in  the  performance  of  the  operation  until  the  in- 
cision into  the  trachea  was  made.  Five  cartilages  being 
incised,  I  was  astonished  not  to  find  the  peculiar  strong 
gushing  sound  of  sudden  respiration;  so  much  the  more  I 
hurried  to  insert  the  tube,  which  after  repeated  attempts 
I  found  impossible.  Thinking  the  trachea  might  be  ab- 
normally narrow,  I  tried  to  introduce  the  inner  tube  only; 
impossible.  I  then  inserted  an  elastic  catheter,  but  could 
not  succeed  in  introducing  it.  Meanwhile,  the  child  died. 
Fearing  I  had  not  opened  the  trachea  at  all,  and  pushed 

245 


DR.    JACOBI'S    WORKS 

my  instrument  downward  in  front  of  the  trachea  in  the 
loose  cellular  tissue,  I  removed  the  dilator  and  found  the 
incision  correct.  I  then  forced  a  silver  probe  into  the 
trachea,  and  felt  some  hard  mass  giving  way  after  some 
pressure.  The  problem  was  then  easih'  solved.  The 
trachea  and  bronchi  were  densely  filled  with  membrane,  my 
incision  had  penetrated  the  trachea  but  not  the  membrane, 
thus  my  tube  doubled  the  membrane  inside  the  trachea,  de- 
taching it  from  its  anterior  wall;  and  thus,  the  child  was 
strangled  in  the  attempt  to  save  her  life. 

Carbonic  acid  poisoning,  asphyxia,  6.  Operation  per- 
formed too  late. 

Anaemia  and  exhaustion,  3. 

General  diphtheria,  8. 

Bronchitis,  6. 

Broncho-pneumonia,  15.  Two  of  these  died  soon  after 
the  operation;  one,  a  case  of  Dr.  Blumenthal's,  in  which 
the  diagnosis  of  the  complication  could  not  be  made  before 
the  operation,  in  consequence  of  the  laryngeal  sounds  cover- 
ing the  auscultatory  symptoms  belonging  to  the  lungS; 
half  an  hour  after  the  opening  of  the  windpipe. 

Bilateral  croupous  pneumonia,  1. 

Broncho-pneumonia  and  gangrene  of  the  lungs,  1.  A 
girl  of  ten  years,  in  157  Eldridge  Street,  in  whose  neigh- 
borhood a  large  number  of  cases  of  diphtheria  and  croup 
occurred  at  that  very  time,  1864,  showed  the  symptoms  of 
general  diphtheria  on  the  first  day  after  the  operation. 
Every  accidental  sore  on  her  skin  became  covered  with 
diphtheritic  membranes,  and  the  wound  assumed  a  fearful 
character.  The  diphtheritic  necrosis  of  the  tissue  crept 
along  the  margin  of  the  wound,  along  the  intermuscular 
tissue,  dissected  as  it  were  the  single  muscles,  destroyed 
part  of  them  and  the  whole  of  the  surrounding  cellular 
tissue,  destroyed  part  of  the  cartilages  until  the  tracheal 
wound  was  more  than  an  inch  in  length,  and  one-third  of 
an  inch  in  width,  so  that  the  tube  moved  freely  in  the  large 
aperture.  On  the  fifth  day  extensive  broncho-pneumonia, 
and  on  the  eighth  gangrene  of  the  lungs  commenced  to 
show  its  fearful  symptoms.  The  girl  died  on  the  thir- 
teenth day. 

246 


TREATMENT    OF    CROUP 

Uncomplicated  pulmonary  oedema  (the  case  spoken  of 
above).  1. 

Suffocation  from  the  membranous  deposits  extending 
into  the  smallest  ramifications  of  the  bronchi,  5.  Four 
of  them  died  on  the  third  day;  two  exactly  after  sixty 
hours.  One,  a  patient  of  Dr.  Ranney's,  on  the  fifth  day. 
All  of  these  cases  did  apparently  well  for  some  time,  until 
the  exudative  process  showed  its  presence  far  below.  In 
some  the  process  did  not  stop  at  all  after  the  operation, 
but  went  gradually  on.  In  some  there  was  a  complete 
rest,  or  intermission,  and  the  chances  very  good  indeed, 
thus  in  Dr.  Ranney's  case  for  three  days.  Then  at  once, 
the  process  would  commence  anew  and  not  terminate  until 
death. 

Miliary  tubeculosis,  1.  A  little  girl  had  suffered  from 
broncho-pneumonia  some  time  previous ;  was  reported  to 
have  recovered,  but  to  have  remained  feeble.  On  the 
third  day  after  the  operation  a  violent  fever  set  in,  with 
general  bronchitis.  She  died  within  thirty-six  hours  after. 
The  post-mortem  examination  revealed  an  abscess  half  an 
inch  in  diameter  in  the  upper  lobe  of  the  left  lung,  and 
cirrhosis  of  part  of  the  same  lobe,  and  miliary  tuberculo- 
sis of  recent  date. 

Exhaustion  and  pneumonia,  1.  This  was  a  very  unfor- 
tunate case  of  the  following  description:  A  little  girl 
of  four  years,  a  patient  of  Dr.  Levings',  appeared  to  do 
well  after  the  operation,  for  some  days.  I  commenced 
local  cauterization  of  the  larynx  for  the  purpose  of  re- 
moving the  membranes  on  the  second  day,  and  continued 
the  same  every  day  until  the  fifth.  I  held  the  solid  stick 
of  nitrate  of  silver  by  means  of  a  forceps  which  I  in- 
troduced into  the  trachea,  end  upward.  With  an  unex- 
pected movement  of  the  child,  I  lost  hold  of  the  caustic, 
which  fell  downward  and  was  not  recovered.  Incessant 
and  violent  coughing,  day  and  night,  with  rare  intermis- 
sions, was  the  next,  pneumonia  the  final  result.  The  child 
died  on  the  ninth  day.  The  post-mortem  examination  re- 
vealed no  tracheitis,  no  bronchitis  in  the  ramification  of  the 
first  order,  little  injection  in  those  of  the  second.  A  piece 
of  nitrate  of  silver  sticking  to  the  inner  side  of  the  right 

247 


DR.    JACOBI'S    WORKS 

large  bronchus  immediately  imbedded  in  a  thick  albumin- 
ate, and  not  entirely  obstructing  the  lumen.  No  injection 
in  the  neighborhood  of  the  lining  membrane.  Old  caseous 
infiltration  by  the  hundred  in  the  two  upper,  and  the  mid- 
dle lobe  of  the  right  lung.  A  recent  hepatization  in  the 
middle  lobe  of  the  right  lung,  and  in  the  two  lower  lobes. 
Dr.  Lothar  Voss  has  placed  at  my  disposal  the  statistics 
of  his  operations  of  tracheotomy  performed  for  croup  be- 
tween 1853  and  1867.  He  has  operated  forty-three  times, 
on  twenty-three  boys  and  twenty  girls.  Of  the  twenty- 
three  boys,  four  recovered;  of  the  twenty  girls,  six. 

How  much  the  prevalence  of  general  diphtheria  ap- 
pears to  have  interfered  with  the  results — a  fact  which 
has  also  been  proved  by  my  own  experience,  as  I  have  no 
case  of  recovery  for  instance  in  1865 — is  shown  by  the 
fact  that  of  his  six  cases  operated  before  the  end  of  1858, 
five  recovered;  while  of  the  remaining  thirty-seven  oper- 
ated upon  between  1859  and  1867,  but  five  recovered.  Three 
of  his  cases  were  under  two  years,  namely,  1  year  1  month, 
1  year  8  months,  1  year  11  months,  all  of  them  girls,  none 
of  whom  recovered.  The  only  fatal  case  in  1858,  the  sixth 
of  the  number,  was  successful  enough  as  far  as  tracheotomy 
itself  is  concerned,  although  it  is  counted  among  the  unfa- 
vorable cases,  the  tube  being  removed  on  the  ninth  day. 
The  child  appeared  quite  well,  but  feeble.  General  and  lo- 
cal diphtheria  set  in,  of  which  and  of  the  consecutive 
anaemia,  the  child  died  on  the  thirty-first  day  after  the 
operation. 

The  ages  of  the  children  on  whom  Dr.  Voss  has  op- 
erated are  the  following:  1  to  2  years,  three  cases;  2 
to  3  years,  fifteen;  3  to  4  years,  ten;  4  to  5  years,  eleven; 

5  to  6  years,  two;  6  to  7  years,  one;  and  7  to  8  years, 
one. 

Of  those  who  recovered,  the  age  was  4  years  2  months ; 
4  years;  4  years  3  months;  3  years;  4  years;  2  years 
4  months ;  2  years  6  months ;  2  years  6  months ;  2  years 

6  months;  and  6  years  5  months. 

In  these  ten  cases  the  tube  remained  8,  6,  8,  19,  14, 
14,  8,  8,  5,  6  days.  Some  delay  took  place,  usually, 
before  the  wound,   which   I,  in   my  cases,  have   found   to 

248 


TREATMENT    OF    CROUP 

heal  very  fast,  would  close  and  remain  so.  Thus,  a 
complete  closure  required  in  nine  cases  18,  21,  IQ,  26,  25, 
25,  30,  22,  17  days.     On  the  tenth  there  is  no  record. 

There  are,  besides,  three  cases  which  virtually  belong  to 
the  recoveries,  as  far  as  the  operation  and  its  influence  on 
the  laryngeal  obstruction  is  concerned.  A  child  of  2  years 
10  months  was  operated  upon,  the  tube  could  be  removed 
on  the  ninth  day,  but  before  perfect  union  of  the  wound 
had  taken  place,  general  diphtheria  set  in,  and  destroyed 
the  patient  on  the  thirty-first  day;  a  child  of  2  years  2 
months  had  the  tube  removed  on  the  seventh  day,  and  died 
of  bronchitis  on  the  eighth;  and  a  third  one,  of  5  years 
2  months,  after  the  tube  had  been  removed  on  the  eighth 
day,  died  on  the  sixteenth  of  pneumonia  and  consecutive 
pulmonary  abscesses. 

Death  occurred,  after  the  operation,  in  thirty  cases, 
which  have  been  accounted  for:  within  twelve  hours  in 
five  cases;  within  1  day  in  three;  1  to  2  days  in  four; 
2  to  three  days  in  five;  3  to  4  days  in  five;  5  days  in  two; 
6  to  7  days  in  two;  10  days  in  one;  l6  days  in  one;  and 
31  days  in  one. 

And  the  causes  of  death  are,  according  to  the  Doctor's 
account  of  thirty  cases,  the  following:  anaemia  in  one; 
convulsions  in  two;  asphyxia  in  two;  croup  descending  into 
the  bronchial  tubes,  eighteen,  (three  of  these  were  com- 
plicated with  general  diphtheria,  two  with  convulsions;) 
emphysema  in  two;  pneumonia  in  three,  (two  of  which 
resulted  in  pulmonary  abscesses;)  bronchitis  in  one;  and 
suffocation  by  accidental  removel  of  tube  in  one. 

Mr.  Chairman,  I  hold  in  my  hands,  besides  the  statis- 
tics of  my  own  sixty-seven  and  Dr.  Voss's  forty-five  cases, 
a  list  of  fifty-six  cases  of  tracheotomy  performed  for  croup 
by  Dr.  E.  Krackowizer,  our  townsman.  Of  his  fifty-six 
cases,  fifty-five  belong  to  this  city,  one  to  Europe  (fatal). 
He  operated  on 

23  in  1852-60,  with  5  recoveries,  and  18  deaths. 

6    "  1861,  "  3  "  3         " 

4  "  1862,          «  1             ..  3 
6    "  1863,           "  3             "  3 

5  "  1864,  "  3  "  2 

249 


DR.    JACOBI'S    WORKS 

6   in    1865,      with    1    recovery,   and      5   deaths. 

2  "    1866,  "       _  "  2 

3  "    1867,  "      _  «  3 

55  16  39 

The  causes  of  death  were  croup  and  bronchitis,  thirty; 
infectious  diphtheria,  three;  scarlatina,  one;  tracheal  gran- 
ulations and  attacks  of  dj-spncea,  and  exhaustion,  54  days 
after  the  operation,  and  4  weeks  after  the  wound  healed, 
one;  exhaustion  and  pulmonary  oedema,  four;  suffocation 
during  the  operation,  one.     Total,  forty. 

I  further,  Mr.  Chairman,  in  presenting  this  fourth  list 
of  statistics  to  you  and  the  Societj^,  desire  to  pay  due  hom- 
age to  the  memory  of  a  deceased  physician  who  is  re- 
membered by  a  number  of  those  present,  although  over 
his  accomplishments  and  expectations  the  grave  has  been 
closed  these  last  ten  years.  Dr.  Waldemar  von  Roth  was 
the  first  among  us  who  operated  extensively  for  croup; 
and  if  he  ha(J  no  other  merit  to  fall  back  upon,  that  would 
be  sufficient  that  his  memory  should  never  die  out  from 
among  both  his  professional  brethren,  and  the  public.  Be- 
tween August,  1852,  and  January,  1856,  he  operated  on 
forty-eight  cases,  eleven  of  which  recovered.  Of  the  thirty 
boys  9,  and  of  the  eighteen  girls  2,  recovered.  He  re- 
cords in  1852,  six  operations,  and  two  recoveries;  in  1853, 
eleven  operations,  and  three  recoveries;  in  1854  sixteen 
operations,  and  two  recoveries;  in  1855,  nine  operations, 
and  two  recoveries;  and  in  1856,  six  operations,  and  two 
recoveries. 

My  last  statements  have  been  rather  cursory,  Mr.  Chair- 
man, as  I  have  been  afraid  of  taxing  your  patience  too 
largely.  I  shall  consider  it  my  duty,  as  this  subject  has 
come  up  for  consideration,  to  present  all  the  statistics 
from  which  I  have  drawn  to-night,  to  the  medical  public. 
What,  however,  my  object  has  been,  in  speaking  of  a 
subject  on  which  every  one  has  obtained  more  or  less 
knowledge,  is  clear.  I  meant  to  sift  vague  or  misunder- 
stood doctrines,  to  show  that  no  harm  is  done  by  acknowl- 
edging the  limits  of  our  science  and  art,  to  prove  that  it 
is  of  more  importance  to  know  what  cannot  be  accomplished 

250 


TREATMENT    OF    CROUP 

by  tlie  internal  administration  of  medicines  than  to  fight 
an  overpowering  enemy  with  remedies,  the  number  of  which 
is  surpassed  only  by  their  powerlessness,  and  finally,  to 
state  the  results  of  tracheotomy  in  more  than  two  hundred 
cases  of  croup,  every  one  of  which  would,  surely,  have 
perished  without  it.  Let  those  fifty  doomed  children  saved 
by  the  operation,  and  let  those  whose  sufferings  were  at 
least  alleviated,  plead  before  you  the  cause  of  tracheotomy. 


251 


CHOLERA  INFANTUM 

Healthy  infants  have  a  normal  tendency  to  loose,  liquid, 
or  semi-liquid  evacuations  from  the  bowels.  The  cause  of 
this  looseness  lies  partly  in  the  condition  of  the  intestinal 
tract,  and  partly  in  the  nature  of  the  normal  food,  which 
is  breast  milk.  Peristaltic  movements  in  the  healthy  child 
are  very  active.  The  young  blood-vessels  and  lymph  ducts 
are  very  permeable,  and  the  transformation  of  the  surface 
cells  is  very  rapid.  In  this  way  transudation  from  blood- 
vessels and  the  lymph  bodies  of  the  intestine  is  facilitated. 
The  peripheral  nerves  are  very  superficial,  more  so  than 
in  the  adult,  whose  mucous  membrane  and  submucous  tis- 
sue have  undergone  thickening  both  by  normal  develop- 
ment and  morbid  processes.  In  the  young  infant  the  pe- 
ripheral ends  of  the  nerves  are  longer  in  proportion  than 
in  the  adult.  The  anterior  horns  in  the  nerve  centres  are 
more  developed  than  the  posterior  ones.  Moreover,  through 
the  defective  development  of  the  inhibitory  centres,  the 
reflex  irritability  of  the  young,  particularly  with  regard  to 
intestinal  influences,  is  greater.  Besides,  the  retentive 
action  of  the  sphincter  ani  is  not  very  powerful;  the  faeces 
are  not  retained  in  the  colon  and  rectum,  which  is  straight 
and  adjacent  to  the  steep  infantile  sacrum,  and  but  little 
time  is  generally  aff"orded  for  the  reabsorption  of  the  liquid 
part  of  the  intestinal  contents.  All  this  illustrates  the 
facility  with  which  a  moderate  or  even  a  copious  elimina- 
tion of  liquid  stools  may  take  place. 

Moreover,  the  frequency  of  acids,  sometimes  normal,  in 
the  small  intestine,  gives  rise  to  the  formation  of  alkaline 
salts  with  purgative  properties.  Hoppe-Seyler  found  free 
acids  in  the  faeces  in  dogs  and  the  human  adult.  Weg- 
schneider  met  them  in  nurslings  who  received  nothing  but 
mother's  milk.  An  explanation  of  this  occurrence  may  be 
found  in  the  fact  that  the  quantity  of  food  is  often  too 

253 


DR.    JACOBI'S    WORKS 

large;  but  in  many  instances  the  amount  of  digestive  fluid 
is  too  small,  and  thus  fermentation  is  caused  in  place  of 
normal  digestion.  Moreover,  the  diastatic  effect  of  the  pan- 
creatic juice  is  limited  at  a  very  early  age,  and  undigested 
material  is  carried  off.  In  this  way,  the  movements  may 
become  quite  loose,  without  the  occurrence  of  extensive  or 
deep  anatomical  alterations.  Superficial  changes,  however, 
may  take  place;  they  consist  in  the  hyperaemia  of  the 
surface  in  rapid  transmutation  of  epithelium,  and  the  for- 
mation of  mucus. 

Most  cases,  however,  of  actual  diarrhoea  originate  in  ex- 
cessive peristalsis,  which  may  be  either  local  or  general. 
If  it  be  limited  to  the  small  intestine  exclusively,  the 
contents  retained  in  the  colon  may  become  dry,  and  the 
presence  of  hyperperistalsis  in  the  former  may  then  be 
doubtful.  It  may  be  caused  firstly  by  irritation  of  local 
(intestinal)  origin,  or  secondly  by  irritants  furnished  either 
by  the  nervous  system  or  by  the  blood. 

The  first  class  embraces  improper  and  indigestible  foods, 
or  excessive  quantities.  The  abnormal  composition  of 
mother's  milk  is  an  occasional  cause.  Mothers  who  are 
sick,  or  convalescing,  or  subject  to  strong  emotions,  those 
who  nurse  too  often,  or  suffer  from  tuberculosis  or 
syphilis  or  anaemia,  or  are  pregnant  or  menstruating,  do 
or  may  secrete  an  anomalous  milk.  The  colostrum  secreted 
immediately  after  childbirth  may  cause  diarrhoea;  so  may 
milk  which  contains  too  much  either  of  fat,  or  casein,  or 
sugar,  or  salts.  It  is  mainly  the  casein,  whose  coagulation 
causes  more  intense  disorders  in  the  young  than  the 
causes  leading  to  stercoraceous  diarrhoea  in  the  adult.  An 
excess  of  fat  is  very  irritating  by  the  formation  of  acid. 
It  is  true  that  it  is  not  the  only  element  of  perturbation 
in  the  usual  food  of  the  young,  viz.,  milk.  The  milk  sugar 
and  albumin,  as  well  as  the  fat,  may  give  rise  to  the  de- 
velopment of  acids.  In  that  respect  the  albuminoids  (casein 
principally)  are  not  very  injurious,  even  milk  sugar  is  but 
moderately  so;  but  as  the  oxidizing  power  is  greatly  re- 
duced in  gastrointestinal  disorders,  the  products  of  the 
decomposition  of  fat  are  very  active.  Together  with  fat 
acids,  carbonic  acid  and  sulphide  of  hydrogen  are  formed. 

251, 


CHOLERA    INFANTUM 

Their  irritating  effect  may  give  rise  to  hypersecretion, 
only,  but  frequently  leads  to  catarrh.  A  similar  effect  is 
caused  by  purgatives,  mainly  by  salts  either  medicinal  or 
contained  in  fruit  or  certain  abnormal  milks.  Parasites 
act  similarly,  from  lumbricoids  to  trichomonads  or  amoebae. 
It  is  true  that  when  present  they  have  not  always  caused 
the  liquid  stools  in  which  they  are  found — indeed,  in  a 
case  lately  observed  of  intestinal  ulceration  of  long  duration 
trichomonads  were  not  found  for  months,  until  at  last  they 
appeared  in  incredible  numbers,  thus  suggesting  that  it  was 
the  abnormal  condition  of  the  intestine  and  of  its  con- 
tents which  facilitated  their  existence,  and  not  vice  versa. 
But  the  occasional  improvement  of  diarrhoeal  diseases  after 
the  removal  of  such  parasites  allows  of  but  little  doubt 
that  they  may  be  the  actual  cause  of  the  liquid  and  of- 
fensive stools  in  which  they  are  found. 

The  intestines  may  be  irritated  by  changes  of  innerva- 
tion, less,  it  is  true,  in  infants  and  children  than  in  adults. 
Experiments  on  the  pneumogastric,  sympathetic,  and 
splanchnic  nerves  have  furnished  ample  proofs  of  their 
influence  on  intestinal  secretion  and  peristalsis,  but  it  is 
mainly  clinical  observation  which  has  established  its  ex- 
istence. Trousseau  discoursed  extensively  on  nervous  diar- 
rhoea. The  gastric  and  intestinal  crises  of  tabes  dorsalis 
are  frequent  occurrences.  Beard  quoted  both  constipa- 
tion and  diarrhoea  among  the  symptoms  of  neurasthenia; 
Mobius  claims  the  same  for  migraine;  the  action  of  tobacco 
is  of  daily  experience.  Nor  is  it  out  of  place  to  remember 
the  influence  of  rapid  changes  of  temperature  among  the 
most  frequent  causes  of  diarrhoea,  in  all  seasons,  and  for 
all  ages.  Thus  the  prevalence  of  bacteria  and  toxins  in 
our  etiological  reasonings  should  not  be  able  to  dislodge 
reflex  hyperaemia  and  secretion  from  their  correct  places 
as  causes  of  disease.  Like  the  nasal  mucous  membranes, 
the  intestinal  surface  is  profoundly  and  suddenly  influenced 
by  colds.  Wet  feet  and  exposure  of  the  perspiring  skin 
to  a  cold  or  draught  will  convince  the  most  obstinate  and 
exclusive  claimant  of  bacterial  rights  of  his  dependence  on 
other  external  factors. 

Intestinal  irritation,  with  peristalsis  and  hypersecretion, 

255 


DR.    JACOBI'S    WORKS 

is  often  caused  by  changes  in  the  blood.  Pilocarpine,  or 
salines  and  other  purgatives  injected  under  the  skin  cause 
diarrhoea.  So  does  uraemia,  sometimes  without  any  ana- 
tomical alterations  of  the  pale  mucous  membrane,  other 
times  with  catarrhal,  ulcerous,  or  croupous  changes  de- 
pending on  the  action  of  ammonium  carbonate.  Extensive 
burns  of  the  surface  of  the  body  exhibit  similar  results. 
They  are  also  observed  in  malarial  poisoning.  Infections, 
such  as  those  in  lobar  pneumonia,  influenza,  erysipelas,  and 
septicaemia,  may  cause  intense  diarrhoea,  with  or  without 
visible  alterations.  Even  typhoid  fever  may  give  rise  to 
extensive  transudations  without  either  catarrh  or  ulcera- 
tions of  the  mucous  membranes.  That  is  mainly  so  in  a 
certain  number  of  young  patients,  in  whom  Peyer's  plaques 
are  but  slightly  developed  and  but  slightly  changed.  Ho- 
denpyl's  latest  researches  prove  that  even  without  glandular 
changes  typhoid  fever  may  exhibit  all  sorts  of  typhoid 
symptoms.  Asiatic  cholera,  finally,  by  its  toxin,  which  is 
absorbed  and  reaches  the  intestinal  glands,  results  by  hy- 
persecretion and  failing  absorption,  in  very  copious  dis- 
charges. We  shall  see  that  cholera  infantum  exhibits  the 
same  symptoms. 

SYMPTOMS 

Cholera  infantum  may  be  preceded  by  symptoms  of 
gastric  or  intestinal,  or  gastrointestinal  catarrh,  but  is  fre- 
quently ushered  in  without  any  prodromi.  Vomiting  and 
diarrhoea,  often  diarrhoea  without  vomiting,  with  either  a 
moderate  or  a  high  elevation  of  temperature,  are  the  first 
symptoms.  Vomiting  follows  the  ingestion  of  food  or  drink 
immediately,  and  may  be  continued  without  this  cause.  In 
the  latter  case  nothing  but  mucus  and  a  serous  fluid,  later 
bile,  are  brought  up ;  the  latter  in  small  quantity,  until  its 
secretion  and  elimination  stop  altogether.  The  alvine  dis- 
charges are  copious  and  numerous,  from  half  a  dozen  to 
two  dozen  a  day.  They  are  acrid  at  first,  alkaline  after- 
wards, and  watery.  They  contain  no  bile  but  large  masses 
of  intestinal  epithelia  and  bacteria.  The  abdomen  is  soft. 
The  thirst  is  intense,  the  pulse  small  and  frequent,  the 
voice  hoarse  or  gone,  the   fontanelle   depressed,  the  skin 

256 


CHOLERA    INFANTUM 

cool  and  inelastic  to  such  an  extent  that  it  can  be  raised 
in  folds.  At  this  time  the  temperature  of  the  cavities,  if 
it  was  high  at  all,  sinks  to  or  below  its  normal  level. 
The  cornea  becomes  turbid,  respiration  difficult,  and  general 
collapse  sets  in.  The  rapid  loss  of  water  from  the  circu- 
lation results  in  anuria  and  in  thickening  of  the  blood,  by 
which  are  caused  cerebral  symptoms  depending  on  the 
slowness  of  intracranial  circulation,  or  on  actual  thrombo- 
sis. Listlessness  with  exhaustion,  and  convulsions  when  oc- 
curring from  these  sources  are  called  hydroencephaloid. 
They  are  complicated  with  those  caused  by  uraemia,  which 
originates  in  the  absence  of  renal  secretion.  The  latter  does 
not  depend,  however,  on  the  copious  loss  of  liquid  through 
intestinal  oversecretion  alone,  but  also  on  actual  nephritis, 
which  is  recognized  by  the  presence  of  red  blood  cells 
and  leucocytes,  and  of  hyaline,  epithelial,  and  granular 
casts  in  the  small  amount  of  urine  either  spontaneously 
evacuated  or  secured  by  catheterization.  If  the  patients 
live  long  enough,  they  develop  in  the  lower  extremities 
sclerema  which  has  the  tendency  to  ascend  slowly.  Chronic 
cases,  or  those  which  turn  to  a  slow  recovery,  are  also 
apt  to  cause  furunculosis  of  long  duration,  with  frequent 
relapses,  great  suffering,  and  possibly  change  into  actual 
septicopyaemia.  Pneumonia,  pleurisy,  peritonitis,  and  men- 
ingitis may  follow.  They  may  be  the  results  of  thrombo- 
sis, or  of  the  original  microbic  infection  which  need  not, 
and  seldom  does,  limit  itself  to  the  intestinal  tract.  Alto- 
gether the  symptoms  of  the  different  stages  of  cholera  in- 
fantum are  explained  in  two  ways,  either  by  the  direct 
intoxication,  or  by  the  abstraction  of  fluids  from  the  or- 
ganism. 

COMPLICATIONS 

One  of  the  most  interesting  complications  or  sequelae 
of  cholera  infantum,  indeed  of  all  such  intestinal  disorders 
as  present  or  furnish  toxins',  is  that  with  renal  derangement 
or  disease.  Like  the  liver,  the  kidneys — while  their  tissues 
are  normal — eliminate  microbes  from  the  blood  (Biedl  and 
Kraus).^  This  process  is  increased  by  diuresis,  an  obser- 
vation which    is   of   considerable   value    for   therapeutics. 

257 


DR.    JACOBI'S    WORKS 

The  first  functional  change  is  albuminuria.  It  may  be  of 
no  account  even  when  it  is  cyclical,  and  when  it  makes 
its  appearance  only  when  the  patients  are  out  of  bed, 
and  differs  greatly  in  its  import  from  the  formation  of  casts 
which  depend  on  morbid  processes  either  in  the  secreting 
epithelium  or  in  the  intercellular  substfeince.  Genuine 
nephritis,  either  parenchymatous  or  intercellular,  occasion- 
ally with  shrinking,  with  hemorrhage,  rarely  amyloid,  and 
seldom  exhibiting  dropsy,  retinitis,  vascular  tension  or 
cardiac  hypertrophy,  is  a  very  frequent  result  of  intestinal 
toxicity.  In  a  small  hospital  containing  little  more  than 
forty  beds,  I  noticed  lately  at  the  same  time  four  cases 
of  nephritis  evolving  out  of  and  accompanying  protracted 
colitis. 

PATHOLOGICAL    ANATOMY 

When  the  disease  has  lasted  only  twenty-four  hours 
there  may  be  few  or  no  changes  in  the  gastrointestinal  mu- 
cous membrane.  When  it  has  lasted  longer,  the  mucous 
surface  is  deprived  of  its  epithelium  (under  the  influence 
of  excessive  fermentation  and  secretion  brought  about  by 
toxins,  nerve  influence,  or  ingesta).  Between  the  gastric 
glands  round  cells  are  deposited  in  large  numbers  in  the 
mucous  membrane  of  the  stomach.  The  gland  cells  are 
swollen,  and  according  to  Fischl  and  Heubner-  their  nuclei 
are  stainable  only  with  great  difficulty.  The  same  round- 
cell  proliferation  takes  place  in  the  lower  parts  of  the  in- 
testinal tract;  here  also  the  epithelium  of  the  villi  is  thrown 
off.  The  blood-vessels  are  dilated  and  filled  with  blood. 
Lieberkiihn's  glands  are  rarely  intact;  they  exhibit  funnel- 
like dilatations  and  an  increase  of  cells,  which  is  also 
manifest  in  other  glands.  Peyer's  plaques,  too,  are  large 
and  rich  in  newly  formed  cells,  which  are  also  found  be- 
tween the  muscles.  Microbes  are  met  with  in  large  num- 
bers and  in  many  varieties.  Bacterium  lactis  aerogenes 
mostly  in  the  upper  part  of  the  bowels,  and  B.  coli  com- 
mune mostly  in  the  colon,  are  common.  Among  them  there 
are  streptococci  and  liquefying  bacilli  which  are  inconstant 
though  frequent  in  all  sorts  of  diarrhoea.  So  far  as  bac- 
terium coli   commune  is   concerned,  it  was   discovered  by 

258 


CHOLERA    INFANTUM 

Escherich  in  1885.  At  that  time  it  was  considered  to  be 
harmless.  But  in  1889  it  was  found  by  Larnette  in  two 
eases  of  perforation  peritonitis;  its  cultures  caused  experi- 
mental peritonitis  in  animals.  Since  that  time  it  has 
been  met  with  in  many  tissues  of  the  human  body,  into 
which  it  has  emigrated  during  the  moribund  state  or  after 
death;  but  it  appears  also  to  be  settled  that  it  may  cause 
inflammation,  suppuration,  and  sepsis  in  many  diseases,  such 
as  enteritis,  colitis,  typhlitis,  peritonitis,  cystitis,  pyelone- 
phritis, cholecystitis,  meningitis  angina,  pneumonia,  endo- 
carditis, arthritis,  salpingitis,  endometritis,  lymphangitis, 
panaritium,  gas  phlegmon,  and  puerperal  fever.  Lately  a 
case  of  peri-  and  endometritis  was  published  by  Uhlen- 
huth,^  who  claims  that  in  his  patient  the  bacterium  coli 
exhibited  three  different  degrees  of  virulence. 

Like  Escherich,  Booker  found  no  specific  bacteria  in 
diarrhoeas,  but  mixtures  of  many;  proteus  vulgaris  was 
mostly  found  in  the  colon,  also  in  the  stomach,  least  in  the 
small  intestines.  When  streptococci  are  extensively  met 
with,  they  give  rise  to  symptoms  resembling  an  irregular 
typhoid  fever,  and  depending  either  on  streptococcal  infec- 
tion or  on  the  absorption  of  a  toxin.  All  of  them  are 
or  may  be  the  causes  of  the  palpable  changes  in  the  in- 
testinal surface;  when  they  are  severe  and  lead  to  ulcera- 
tion, microbes  may  be  swept  into  the  circulation.  In  this 
way  the  lungs  are  known  to  be  infected.  Still  it  should 
here  be  emphasized  that  intestinal  ulceration  does  not  al- 
ways require  the  presence  and  action  of  bacteria  to  any 
or  to  such  a  degree  as  in  diphtheritic  or  gangrenous  colitis, 
where  they  are  mostly  in  evidence. 

The  contents  of  the  bowels  are  copious  and  thin,  exactly 
like  those  which  are  observed  in  children  who  have  died  of 
convulsions  during  the  hot  season.  In  sunstroke  both  the 
stomach  and  the  intestines  are  apt  to  be  found  in  the  same 
condition.  This  similarity  is  very  suggestive.  It  appears 
to  show  that  cholera  infantum,  when  fatal  on  the  first 
day,  proves  so  by  paralysis  exactly  as  in  insolation.  At 
that  early  time  surely  cholera  infantum  is  not  yet  enteritis. 
This  is  primary  in  the  other  forms  of  intestinal  overse- 
cretions;   in   cholera   infantum  it  is   secondary.     The  kid-» 

259 


DR.    JACOBI'S    WORKS 

neys  are  large  and  pale,  with  fatty  degeneration  of  the 
parenchyma,  and  sometimes  pus  in  papillae  and  calyces. 
Bacterial  emboli  are  rare,  certainly  much  rarer  than  in  the 
lungs.  The  liver  shows  the  same  cloudy  swelling  of  the 
parenchyma  which  is  met  with  in  the  kidneys.  Other  patho- 
logical changes  are  the  intense  rigor  mortis,  and  the  dark 
color  and  defective  coagulability  of  the  blood.  The  me- 
ninges and  the  lower  part  of  the  lungs  are  hyperaemic. 

These  results  were  partly  found,  and  partly  confirmed  by 
one  of  the  most  industrious  and  careful  of  modern  bac- 
teriologists who  at  the  same  time  is  a  clinician,  Booker, 
who  spent  years  of  labor  on  his  researches  on  the  bacterial 
nature  or  complications  of  the  different  forms  of  intes- 
tinal disorders,  both  light  and  grave.  He  published  ninety- 
two  bacteriological  examinations,  in  all  of  which  he  found 
the  bacterium  lactis  aerogenes  and  coli  commune;  in  most 
of  them  also  streptococci  and  proteus  vulgaris.  The  num- 
ber of  his  autopsies  was  thirty-three;  the  cases  were  classed 
by  him  as  acute  and  chronic  gastroenteritis.  In  the  former 
the  local  alterations  of  the  intestine  were  but  few;  but  the 
general  infection,  including  that  of  the  lungs  in  which  bac- 
teria were  found,  and  that  of  the  spleen  and  kidneys  which 
were  mostly  affected  by  toxins,  was  very  intense.  The 
later  exhibited  many  alterations  both  of  an  inflammatory 
and  a  degenerative  nature,  which  differed  with  the  local- 
ization and  the  destructive  influence  of  the  bacteria.  When 
he  met  with  these  same  results  in  the  living,  the  prognosis 
depended  on  the  clinical  symptoms,  which  differed  widely 
in  individual  cases.  This  observation  of  a  pathologist  who 
is  at  the  same  time  a  clinician  proves  again  the  insufficiency 
of  pathological  anatomy  when  confined  to  the  dead-house, 
or  of  bedside  observation  when  not  guided  by  histological 
and  bacteriological  research. 

The  ubiquitous  appearance  of  a  great  many  varieties 
of  microbes  which  were  present  in  all  sorts  and  grades  of 
intestinal  disorders,  induced  Booker  to  venture  upon  a  class- 
ification which  is  partly  clinical,  and  partly  bacteriological. 
He  distinguishes  three  forms  of  diarrhoeal  diseases:  (First) 
The  dyspeptic  diarrhoea,  with  no  inflammation,  with  no  leu- 
cocytes or  epithelia  in  the  lumpy  acid  stools,  with  plenty 

260 


CHOLERA    INFANTUM 

of  bacteria  coli  coramunia,  and  few  specimens  of  bacterium 
lactis  aerogenes.  This  is  sometimes  an  independent  form, 
but  other  times  the  first  stage  of  (second)  the  streptococcic 
gastroenteritis.  This  has  the  character  of  a  general  in- 
fection, tlie  intestines  are  ulcerated  or  suppurating,  the 
stools  contain  mucus,  leucocytes,  and  streptococci.  These 
are  sometimes  very  numerous,  in  some  instances  mixed  with 
bacteria  coli  communia.  When  cocci  are  prevalent,  the 
cases  are  very  obstinate  and  fatal.  Booker's  third  form 
is  a  bacillary  gastroenteritis.  It  exhibits  less  local  inflam- 
mation than  intense  toxaemia.  A  great  many  varieties  of 
bacilli  are  found,  with  or  without  streptococci.  Not  one 
of  these  three  classes,  however,  is  claimed  as  a  clinical 
or  pathological  entity;  on  the  contrary,  transitions  between 
them  are  pronounced  to  be  very  frequent.* 

After  all,  observers  agree  in  the  absence  of  a  constant 
and  pathognomonic  microbe.  Among  others,  Baginsky  and 
Stadthagen  found  a  body  (probably  basic)  in  the  cultures 
of  a  bacillus  from  cholera  infantum  which  is  probably 
identical  with  one  obtained  by  Brieger  in  decomposing 
horseflesh,  that  is  very  poisonous,  acts  on  frogs  like  curare, 
dilates  the  pupils,  and  stops  the  heart  in  diastole. 

ETIOLOGY 

The  theories  established  for  the  explanation  of  cholera 
infantum  changed  with  those  governing  etiology  in  general. 
Fifty  years  ago  almost  all  the  diseases  of  the  infant,  and 
some  of  the  mother,  were  traced  back  by  Thomas  Ballard 
to  "  fruitless  sucking."  Infant  cholera  was  by  some  con- 
sidered identical  with  Asiatic  cholera.  Some  unknown  at- 
mospheric influence,  sewer  emanations  of  undescribed  na- 
ture, evaporations  of  the  upper  strata  of  the  earth,  ma- 
laria, moisture,  the  oscillations  of  the  barometer,  or  of  the 
subsoil  water  were  charged  with  being  the  causes  of  cholera 
infantum,  with  equal  and  positive  fervor. 

When  etiology  became  more  bacteriological,  microbes 
were  accused,  for  instance,  those  of  the  genus  ascophora,  by 
Bouchut;  others  looked  for  poisons,  as  Sonnenberger,  for 
the  presence  in  the  food  of  plant  alkaloids. 

261 


DR.    JACOBI'S    WORKS 

The  temptation  to  attribute  cholera  infantum  to  the  di- 
rect influence  of  microbes  was  combated  by  the  fact  that 
too  many  of  the  latter  were  found,  and  that  it  became  diffi- 
cult to  identify  a  single  one  as  the  cause  of  cholera  infan- 
tum. Neither  Escherich  nor  Baginsky  nor  Booker  con- 
vinced himself  that  there  was  a  direct  connection  between 
the  presence  of  special  bacteria  with  the  symptoms  of 
cholera  infantum.  Baginsky  found  twenty  species  or  va- 
rieties of  bacteria,  mostly  saprogenous,  none  of  which  could 
be  claimed  as  pathogenous.  Thus  chemistry,  after  having 
long  been  neglected,  had  to  be  called  in.  UfFelmann  and 
Seibert  accused  the  decomposed  milk  sold  in  large  cities, 
Lesage  a  poison  produced  by  some  microbe  not  specific, 
Vaughan  his  tyrotoxican.  The  poisonous  substance  would, 
in  the  opinion  of  many  of  these  authors,  be  evolved  out  of 
milk,  even  out  of  breast  milk.  Difference  of  opinion,  how- 
ever, became  apparent  in  regard  to  the  question  whether 
the  poison  entered  ready  made  with  the  milk,  or  was  de- 
veloped out  of  it  in  the  alimentary  tract  of  the  infant. 
Both  of  these  opinions  are  founded  on  facts ;  in  many  cases 
both  roads  were  found  accessible  to  the  poison. 

The  first  stages  of  cholera  infantum  do  not  look  alike. 
Some  cases  begin  very  abruptly,  others  have  a  sliglit  gas- 
trointestinal disturbance  or  prodrome.  The  patients  are 
less  than  two  years  old.  In  the  vast  majority  the  feeding 
is  artificial,  and  with  but  few  exceptions  the  attacks  occur 
during  the  hot  months  of  the  summer,  on  such  days  as 
furnish  only  a  slight  difference  between  the  tempera- 
tures of  day  and  night,  and  during  the  weeks  following 
them. 

Constant  heat  is  undoubtedly  a  prominent  etiological 
factor.  It  appears,  however,  that  when  and  where  the 
babies  are  habituated  to  a  warm  climate,  they  do  not  suffer 
like  those  who  are  suddenly  exposed  to  excessive  tempera- 
tures. The  differences  of  temperature,  as  collated  by 
Meinert,  between  January  and  July,  are  in  Africa  3.4° 
C.  (6.1°  F.),  in  South  America  4.2°  (7-5°  F.),  in  Aus- 
tralia 13°  (23.4°  F.),  in  central  Asia  and  Europe  26.1° 
(47°  F.),  and  in  North  America  28.4°  C.  (51.1°  F.).  The 
sudden  heats  of  the  temperate  zones  are  among  the  prin- 

262 


CHOLERA    INFANTUM 

cipal  causes  of  cholera  infantum;  in  them  it  is  most  fre- 
quent, though  it  be  found  in  warm  climates. 

How  does  heat  affect  the  babies,  indirectly  or  directly? 
Its  indirect  effect  is  best  appreciated  when  it  is  remembered 
that  breast-fed  babies  do  not  suffer  like  those  artificially 
fed.  Meinert's  observations  in  Dresden*^  yielded  eighteen 
deaths  among  the  former,  four  hundred  and  sixty  among 
the  latter  in  eleven  hot  summer  weeks.  This  agrees  with 
what  every  practitioner  learns  from  his  own  experience. 
That  coarse  and  fermentable  food  leads  to  catarrhal  irri- 
tation of  the  intestine  which  may  precede  cholera  infan- 
tum, or  to  the  formation  of  a  toxin  or  toxins  which  cause 
it  without  a  previous  anatomical  lesion,  is  easily  under- 
stood. 

Is  there  anything  like  a  direct  influence  of  heat  on  the 
baby  with  the  result  of  causing  cholera  infantum.''  It  has 
always  appeared  so  to  me.  In  a  brief  paper  r°ad  before 
the  Verein  Deutscher  Aerzte  in  1858 — it  is  contained  in 
the  minutes  of  the  society — I  took  that  stand;  and  again 
in  1868  in  a  paper®  entitled  "Concerning  the  Neglected 
Causes  of  Infant  Mortality  in  the  City  of  New  York." 
Twenty  years  ago  Clark  Miller'^  pointed  out  the  striking 
resemblance  between  cholera  infantum  and  sunstroke.  He 
claimed  the  symptoms  belonging  to  the  former  as  due  to 
paralysis.      Meinert  shares  his   opinion  to  its   full  extent. 

Both  are  disease  of  the  hot  season,  and  caused  by  un- 
interrupted heat.  Hot  days  relieved  by  cool  nights  are 
well  tolerated;  it  is  the  constant  heat  which  proves  detri- 
mental. Constancy  is  still  more  dangerous  than  temporary 
excess.  A  relatively  lower  temperature,  but  relentless 
and  moist,  demands  most  victims.  High  temperatures  with 
wind  and  drought  are  comparatively  safe;  absence  of  ven- 
tilation is  destructive.  No  wall  ventilation  takes  place 
during  summer;  and  in  the  first  weeks  of  the  autumn  the 
houses  remain  warmer  than  the  surrounding  air,  for  the  soil 
retains  the  temperatures  soaked  in  during  the  summer. 
All  this  is  worse  in  large  cities,  in  crowded  streets,  where 
the  buildings  are  high  and  exclude  wind  and  draught,  in 
narrow  flats  or  tenement  houses,  in  residences  with  scanty 
windows    looking    in    one    direction    only.      In    them    the 

263 


DR.    JACOBI'S    WORKS 

babies  are  housed,  there  they  are  stifled  in  their  beds.  If 
they  be  breast  fed,  they  are  now  and  then  taken  up  and 
changed  about.  If  not,  they  are  given  their  bottles  in  their 
cribs  without  perhaps  changing  their  positions.  Lehmann 
experimented  on  such  babies  buried  in  their  beds,  and  found 
that  they  inhale  four  times  the  amount  of  carbonic  acid 
received  by  those  not  so  buried.  They  are  the  ones  that 
are  liable  to  suffer,  though  or  rather  because  they  are  not 
exposed  to  the  sun,  from  isolation;  they  are  the  very  vic- 
tims of  cholera  infantum.  For  in  addition  they  lack  what 
is  most  essential  to  keeping  up  circulation  and  tissue  meta- 
morphosis, viz.,  water.  Sweltering  in  their  unclean  and 
hot  bed  prisons  they  are  given  the  exact  food  they  receive 
on  cool  days.  The  very  adults  who  will  satisfy  their 
thirst  by  copious  draughts  of  water,  will  never  think  of  giv- 
ing an  extra  allowance  of  it  to  their  starving  young  ones. 
The  breast-fed  infant  is  better  off  in  that  respect  also. 
The  mother  or  nurse,  drinking  ad  libitum,  dilutes  her  milk, 
for  breast-milk  is  no  unchangeable  article  like  the  Gordon- 
Walker  or  Gaertner;  it  may  change  in  certain  limits  its 
percentage  of  constituents  every  hour  of  the  day,  every 
day    of   the   week. 

The  question  whether  heat  causes  cholera  infantum  by 
its  direct  or  indirect  effects  is  therefore  easily  answered. 
It  acts  in  both  ways.  By  fermenting  and  spoiling  the 
baby's  food,  mainly  cow's  milk,  it  produces  deleterious 
ptomains.  By  paralyzing  its  nervous  system  it  causes  the 
characteristic  gastric  and  intestinal  disturbances,  overse- 
cretion  and  non-absorption.  Both  of  these  need  not  coin- 
cide with,  or  depend  on,  catarrhal  or  other  changes  of  the 
alimentary  tract.  But  these  latter  will  become  apparent 
when  the  former  have  lasted  more  than  a  day. 

No  single  cause  will  always  have  a  uniform  effect.  In- 
dividual power  of  resistance  and  vitality  increase  or  lessen 
the  action  of  external  circumstances.  A  certain  predis- 
position is  always  required  to  make  a  living  being  submit 
to  a  morbific  influence.  Not  everybody  suffers  from  inso- 
lation when  exposed  to  protracted  heat.  Nor  is  the  same 
food  equally  dangerous  to  all.  In  the  foundling  hospital 
of  Prague,  under   Epstein's   control,  the  mortality   of  the 

264 


CHOLERA    INFANTUM 

infants  is  excessive;  that  of  the  same  class  of  infants  when 
sent  to  the  country  and  fed  on  the  same  material,  is  com- 
paratively trifling.  In  a  small  ward  of  a  hospital  or  in  a 
private  room  of  a  poorly  equipped  residence  the  mortality 
of  infants  is  not  so  great  as  in  large  wards  or  big  in- 
stitutions. When  thirty  years  ago  I  proved  that  in  such  a 
one  every  infant  that  was  kept  a  few  short  months  died, 
I  was  expelled  for  my  pains.  Still  the  fact  remains 
exactly  so.  One  of  the  most  assiduous  and  learned  pedia- 
trists  of  modern  times,  Heubner,  had  the  same  experience. 
He  expects  the  little  waifs  in  his  hospital  to  live  only  when 
he  is  able  to  transfer  them  to  the  country,  or  to  their  own 
poverty-striken  homes.  Thus  not  even  better  hereditary 
influence,  or  constitution,  or  previous  good  condition  are 
safeguards ;  and  bad  food  alone  is  not  the  only  detriment. 
It  should  not  be  forgotten  that  in  many  cases  the  fatal 
intestinal  disorder  is  of  microbic  origin,  or  is  readily  be- 
coming complicated  with  microbes  and  their  toxins.  They 
are  contagious.  There  is  no  hospital  or  nursery  ward  with- 
out them.  The  clothing  and  bedding  are  soiled,  the  nurses 
stain  their  fingers  with  it,  and  going  from  one  baby  to 
the  other,  feeding,  washing,  changing  clothes,  infect  one 
after  the  other  from  a  single  source.  Infection  of  the  intes- 
tinal tract  takes  place  not  only  through  the  mouth  but  also 
through  the  anus.  This  source  of  infection  is  almost 
unavoidable.  Heubner  succeeded  in  reducing  his  mortality 
by  more  than  twenty  per  cent,  by  simply  employing  a  set 
of  nurses  for  the  exclusive  duty  of  attending  to  the 
diapers,  and  another  set  for  feeding  and  other  attendance. 
As  long  as  a  single  nurse  has  the  whole  attendance  on  a 
number  of  infants,  absolute  cleanliness  of  her  fingers  is 
practically  an  impossibility.  If  in  every  such  institution 
the  mother  could  be  kept  with  her  infant,  the  danger  of 
contagion  would  be  relatively  small. 

DIAGNOSIS 

The  diagnosis  of  "  cholera  infantum  "  becomes  difficult 
only  in  those  cases  which  have  developed  out  of  catarrhal 
conditions    of   the    alimentary    tract    under    the    same    in- 

265 


DR.    JACOBI'S    WORKS 

fluences  which  give  rise  to  all  sorts  of  disturbances,  viz., 
constant  solar  heat  and  inappropriate  feeding.  For  the 
purposes  of  practice  an  exact  diagnosis  in  difficult  cases 
is  perhaps  not  always  very  important.  For  no  matter 
what  the  case  may  be  called,  the  indications  presented  by 
the  local  changes  in  the  alimentary  tract  and  by  the  con- 
stitutional symptoms  exhibited  by  the  patients  are  more  or 
less  identical.  Still  the  diagnosis  of  "  cholera  infantum  " 
from  other  forms  of  gastrointestinal  disturbances  should 
be  made;  in  many  of  the  latter  the  successful  treatment 
depends  on  the  exact  knowledge  of  the  condition  of  the 
bowels.  There  are  several  forms  of  diarrhaea  which  should 
be  known  in  this  connection,  viz.,  fat  diarrhoea,  catarrhal 
enteritis,  and  follicular  enteritis. 

The  name  of  "  fat  diarrhoea  "  was  given  by  Biedert  to 
a  condition  in  which  the  normal  proportion  of  fat  in  the 
infant  faeces,  which  amoiuits  to  from  four  to  twenty-five, 
mostly  from  nine  to  eleven  per  cent.,  is  increased  to  from 
forty-one  to  sixty-seven  per  cent.  In  this  form  of  di- 
arrhoea the  discharges  are  shining  and  glossy  with  fat  of 
yellowish  or  gray  color,  sometimes  greenish,  mixed  with 
mucus,  and  mostly  very  malodorous.  The  fat  molecules 
are  large,  in  the  normal  faeces  small.  It  should  be  re- 
membered, however,  that  the  percentage  of  faecal  fat  is 
liable  to  be  increased  in  every  attack  of  dyspepsia  (Tscher- 
now,   UfFelmann). 

This  fat  diarrhoea  may  be  primary  or  secondary.  The 
first  is  the  direct  result  of  the  ingestion  of  an  excess  of 
fat,  and  is  relieved  by  correcting  the  composition  of  the 
food.  Fat  should  be  diminished,  and  sometimes  withheld 
altogether.  For  some  days  the  substitution  of  egg  water 
(albumen  beaten  up  in  water  or  in  barley  or  toast  water), 
or  of  a  thin  chicken  broth  is  advisable.  There  are  some 
babies  who  from  the  moment  of  birth  bear  milk,  even 
breast  milk,  in  great  dilution  only — an  illustration  of  the 
justice  of  my  demand  of  ample  dilution  of  the  food  given 
to  the  newly-born  and  very  young. 

The  secondary  form  of  fat  diarrhoea,  not  depending 
solely  on  an  excess  of  fat,  is  due  to  catarrhal  conditions 
of  the  intestine,  or  to  disease  of  the  pancreas.     In  autop- 

266 


CHOLERA    INFANTUM 

sies  duodenal  catarrh,  a  large  size  and  dry  condition  of  the 
pancreas,  a  contraction  of  the  orifice  of  the  choledochus 
and  pancreatic  ducts,  parenchymatous  pancreatitis  and 
fatty  degeneration  of  the  liver  have  been  found.  A  mod- 
erate amount  of  the  latter,  however,  is  met  with  under 
normal   conditions  of   the  baby. 

In  intestinal  catarrh  (catarrhal  enteritis)  there  are  fever, 
diarrhoea,  and  pain,  and  when  the  aifection  begins  in  the 
stomach,  vomiting  also.  The  babes  are  pale,  and  draw  up 
their  legs,  and  when  the  catarrh  descends  to,  or  begins  in, 
the  rectum,  there  is  tenesmus.  The  evacuations  in  the 
beginning  contain  remnants  of  food,  and  have  a  stronger 
odor  than  normal  faeces,  still  they  are  not  very  offensive; 
afterwards  they  are  liquid,  light  yellowish  or  brownish  in 
color,  strongly  acid,  but  later  of  an  alkaline  reaction,  with 
many  specimens  of  bacteria  (none  of  which  is  character- 
istic of  the  affection),  epithelium,  mucus,  sometimes  pus, 
and  remnants  of  food  of  all  kinds ;  the  percentage  of 
water  is  very  large,  amounting  to  ninety  to  ninety-five  per 
cent.,  while  in  normal  faeces  of  the  nursling  it  is  but 
eighty-five  per  cent.,  and  in  older  children  eighty  to  seventy- 
five  per  cent. ;  particularly  is  the  percentage  of  water 
large  in  all  those  cases  of  diarrhoea  which  depend  upon, 
or  are  complicated  with,  disturbances  of  the  circulation 
brought  on  by  diseases  of  the  heart,  the  lungs,  or  the 
liver.  If  the  evacuations  were  first  odorless,  they  become 
faecal,  afterwards  acid,  and  in  protracted  cases  and  so- 
called  follicular  enteritis,  cadaveric. 

In  the  beginning  of  the  disease  there  is  sometimes  herpes 
labialis,  and  the  urine  is  diminished  in  quantity,  but  is 
entirely  arrested  only  in  the  very  worst  cases  which  have 
a  tendency  to  become  choleraic.  In  a  few  cases  recovery 
is  quite  rapid;  in  others  the  disease  terminates  in  so-called 
follicular  enteritis,  or  in  chronic  intestinal  catarrh. 

When  there  is  diarrhoea  we  have  to  conclude  that  the 
upper  part  at  least  of  the  colon  is  affected.  Food  remnants 
will  require  two  or  three  hours  to  pass  from  the  pylorus 
to  the  caecum;  until  then  the  contents  are  fluid.  Below  that 
point  they  become  rather  dry;  not  so  when  part  of  the 
colon  is  also  in  a  catarrhal  condition.      Thus,  when  they 

267 


DR.    JACOBrS   WORKS 

are  quite  fluid,  an  affection  of  the  upper  part  of  the  colon 
necessarily  exists  and  results  in  undue  peristalsis. 

Duodenal  catarrh  can  be  diagnosed  only  when  it  is  com- 
plicated with  jaundice,  as,  when  uncomplicated,  it  never 
gives  rise  to  diarrhoea.  Catarrh  of  the  jejunum  and 
ileum  is  seldom  isolated  without  the  upper  part  of  the 
colon  participating  in  the  process,  and  it  must  be  sup- 
posed that  they  are  disordered  when  the  stomach  is  affected 
in  a  case  of  diarrhoea.  When  the  faeces  are  fairly  solid 
and  contain  conglomerate  masses  of  mucus  thoroughly 
mixed  with  the  faecal  masses,  we  make  the  diagnosis  of 
isolated  catarrh  of  the  small  intestine.  Further,  when  the 
faeces  contain  a  great  deal  of  undigested  material  we  may 
also  conclude  that  we  have  to  deal  with  a  complicated 
catarrh,  involving  both  the  small  intestine  and  stomach ; 
this  is  the  condition  in  which  undigested  food  is  seen  in 
the  faeces  ("  lientery  ") .  But  it  must  be  remembered  that 
gastric  catarrh  alone,  with  anaemia  and  abnormal  peristalsis 
of  the  stomach  and  upper  part  of  the  small  intestine,  is 
of  itself  able  to  propel  undigested  food  with  abnormal 
rapidity. 

When  there  is  bile  in  passages  of  green  color,  yielding 
a  distinct  reaction  with  nitric  acid,  and  attached  to  the 
mucus  and  cylindrical  epithelium  and  round  cells,  we  have 
also  to  conclude  that  the  catarrh  has  its  seat  in  the  small 
intestine,  as  under  normal  conditions  there  is  but  very 
little  or  no  bile  in  the  large  intestine. 

It  has  been  stated  that  when  there  is  considerable  per- 
istalsis and  rumbling  (audible  or  perceptible  on  palpation) 
in  the  middle  of  the  abdomen  and  its  lower  part,  the  af- 
fection is  in  the  small  intestine;  that  thej''  are  lateral  and 
in  the  upper  part,  when  the  large  intestine  is  involved. 
Still,  neither  pain  nor  locality  is  absolutely  pathognomonic. 
There  is  one  condition,  however,  that  is  so.  When  the 
mucus  is  not  thoroughly  mixed  with  the  faeces,  when  the 
faeces  are  wrapped  up  in  or  covered  by  it  after  evacuation, 
then  the  mucus  comes  from  the  colon,  and  we  have  to  deal 
with  catarrh  of  this  part  of  the  intestine;  and  when  the 
faeces  are  still  solid,  the  catarrh  has  its  location  in  the 
lower  part  of  the  colon. 

268 


CHOLERA    INFANTUM 

As  a  general  rule,  acute  catarrh  of  the  lower  part  of 
the  colon  generally  furnishes  pure  mucus  mixed  with  blood, 
particularly  in  the  catarrhal  form  of  dysentery.  When  the 
secretion  from  the  colon  is  very  considerable,  the  bowels 
are  evacuated  more  or  less  frequently,  in  large  quantities 
or  smaller  ones,  suddenly  and  with  a  gush,  and  usually 
without  tenesmus,  which  is  observed  only  when  the  lower 
portion   of  the  rectum  is   involved  in  the  morbid  process. 

In  follicular  enteritis  the  pathological  changes  are  those 
of  catarrh,  but  the  most  severe  alterations  take  place  in 
the  solitary  follicles  and  in  Peyer's  patches.  Both  of  these 
are  enlarged  and  prominent,  and  grayish  or  grayish-red, 
the  latter  surrounded  by  a  red  zone;  now  and  then  ulcera- 
tions are  found.  The  microscope  also  reveals  a  large  num- 
ber of  newly  formed  round  cells,  disintegrated  or  not.  In 
the  ulcerations  there  are  large  masses  of  detritus  and  bac- 
teria. The  lymph  vessels  and  lymph  bodies  participate 
in  every  severe  form  of  intestinal  catarrh,  and  there  is 
a  large  amount  of  acute  and  chronic  tumefaction  of  the 
mesenteric  glands. 

The  symptoms  vary  according  to  whether  this  particular 
form  is  connected  with  acute  or  chronic  intestinal  catarrh. 
In  the  first  variety  there  are  fever  and  diarrhoea,  frequent 
and  copious  discharges,  all  accompanied  by  pain ;  the  in- 
clination to  evacuate  the  bowels  is  constant,  and  there  is 
some  tenesmus.  When  the  latter  is  present,  the  passages 
are  small,  greenish,  foamy,  have  an  insipid,  musty,  and 
after  a  while  cadaveric  odor,  are  covered  with  mucus,  some 
blood  and  pus ;  actual  hemorrhage  is  rare.  Under  the 
microscope  are  seen  mucus,  blood,  pus,  and  round  cells, 
unchanged  or  undergoing  disintegration,  and  bacilli  and 
zooglcea. 

The  symptoms  are  liable  to  increase  very  rapidly,  and 
complications  with  pulmonary  diseases  and  peritonitis  are 
not  infrequent.  Although  the  disease  is  a  very  serious 
one,  slow  recovery  may  take  place. 


269 


DR.    JACOBI'S    WORKS 


PROPHYLAXIS 

There  are  many  measures  of  a  public  character  that 
would,  and  could,  be  taken  in  the  interest  of  prevention 
of  cholera  infantum  and  all  other  intestinal  diseases  in  a 
more  advanced  condition  of  public  hygiene.  The  demand 
for  more  air  space  to  the  individual,  for  the  separation  of, 
and  less  stories  in  tenement  houses,  for  protection  against 
the  sun  in  our  streets,  for  extensive  street  sprinkling,  for 
street  cleaning,  for  an  abundance  of  large  and  small  parks 
and  covered  piers,  for  public  baths  reserved  for  infants 
and  children,  for  a  close  and  strict  supervision  of  our 
markets  by  the  health  departments,  will  be  complied  with 
in  some  distant  future  when  human  society  and  the  state 
recognizes  their  responsibilities  to  the  individual  in  con- 
tradistinction to  the  egotism  and  individualism  of  the  pres- 
ent. Indeed  many  questions  of  the  public  hygiene  and 
welfare  are  of  a  social  and  politico-economic  nature  only; 
and  the  safety  of  the  individual  depends  on  the  sense  of 
responsibility  demonstrated  by  the  state  through  its  laws 
and  institutions  established  and  managed  in  the  interest 
of  all. 

Private  houses  and  rooms  should  be  kept  cool  in  summer 
and  well  ventilated.  Our  windows,  which  can  never  be 
opened  more  than  half,  are  badly  arranged.  If  a  prize 
had  been  set  on  faulty  construction  it  would  have  been 
awarded  to  the  man  who  devised  our  present  arrangements 
for  light  and  air.  The  dwellings  in  the  tenements  of  the 
poor,  with  windows  on  one  side  only,  with  an  impossibility 
of  procuring  a  draught,  are  the  main  sufferers  from  these 
windows  of  which  the  upper  half  only  can  be  lowered  or 
the  lower  half  raised. 

No  weaning  should  ever  take  place  in  summer,  except 
for  very  urgent  reasons,  and  with  the  possibility  of  pro- 
curing good  substitutes,  inclusive  of  fresh  or  aseptic  milk. 
To  this  the  most  careful  attention  should  be  given.  No 
family  should  be  without  red  and  blue  litmus  paper,  to 
make  sure  of  the  absence  of  acidity.  Altogether  the  rules 
which  have  been  published  by  the  Health  Department 
of  this  city  these  thirty  years,  with  but  slight  modifications 

270 


CHOLERA    INFANTUM 

of  and  additions  to  my  original  draft  of  1866,  have  proved 
useful  and  successful.*  Diarrhoeas  must  not  be  neglected. 
Diarrhoea  from  "  teething,"  if  it  existed  at  all,  should  not 
be  overlooked  any  more  than  that  depending  on  its  usual 
causes. 

NORMAL    FEEDING 

The  most  important  preventive  of  cholera  infantum  (as 
of  other  intestinal  diseases  or  disorders)  is  appropriate 
and  digestible  food;  in  the  vast  majority  of  cases  this  is, 
for  the  poor  infant,  human  milk.  Whenever  that  cannot 
be  had,  proper  substitutes  should  be  provided.  Among 
them  the  milk  of  the  goat  and  that  of  the  cow  take  the 
highest   rank.      The    former,   however,   contains   too   much 

*  The  original  draft  of  those  rules,  which  was  but  slightly  al- 
tered afterwards,  was  as  follows: 

If  you  nurse  your  baby: 

Do  not  nurse  your  baby  oftener  than  once  every  two  or  three 
hours. 

Do  not  nurse  a  baby  of  more  than  six  months  oftener  than  five 
times  in  twenty-four  hours.  When  it  is  thirsty  in  the  mean  time, 
give  it  cold  water.  In  very  hot  weather  only,  mix  a  teaspoonful 
of  whiskey  with  a  tumblerful  of  water. 

If  you  cannot  nurse  your  baby: 

You  cannot  bring  it  up  without  milk.  But  the  milk  (cow's 
milk)   must  not  be  given  pure,  nor  with  water. 

Boil  a  teaspoonful  of  barley,  ground  in  the  coffee-mill,  with  a 
gill  of  water  and  a  little  salt  for  fifteen  minutes,  then  add  half 
as  much  boiled  milk  and  a  lump  of  loaf  sugar,  and  give  it  luke- 
warm from  a  nursing-bottle. 

Bottle  and  mouthpiece  are  always  to  be  kept  in  water  when  not 
in  use. 

Babies  of  five  or  six  months,  half  barley  water  and  half  boiled 
milk,  with  salt  and  loaf  sugar. 

When  the  bowels  are  costive,  take  farina  instead  of  barley 
flour. 

When  they  are  very  costive,  take  oatmeal  gruel;  strain  it  be- 
fore mixing  with  milk. 

When  you  have  but  half  enough  breast-milk  use  the  same  food. 
Give  the  food  and  breast-milk  alternately  so  that  your  milk  has 
time  to  get  fit  for  your  baby  to  take. 

You  may  give  beef  tea  or  beef  soup  mixed  with  your  barley  or 

271 


DR.    JACOBI'S    WORKS 

casein  and  fat,  besides  being  otherwise  incongruous.  From 
many  of  my  writings,  and  mainly  from  the  second  edition 
of  my  "  Therapeutics  of  Infancy  and  Childhood  "  ^  I  here 
condense  the  following  points: 

The  mixed  milk  of  a  dairy  is  preferable  to  that  of  one 
cow.  Cow's  milk  should  be  boiled  before  being  used.  Con- 
densed milk  is  not  a  uniform  article,  and  its  use  is  pre- 
carious for  that  and  other  reasons.  Skimmed  milk  obtained 
in  the  usual  way,  by  allowing  the  cream  to  rise  in  the 
course  of  time,  is  mostly  objectionable,  because  such  milk 
is  often  acidulated.  The  caseins  of  cow's  and  woman's 
milk  differ  both  chemically  and  physiologically.  The  for- 
mer is  less  digestible.  There  ought  to  be  no  more  than  one 
per  cent,  of  casein  in  every  infant  food.  Dilution  with 
water  alone  may  appear  to  be  harmless  in  many  instances, 
for  some  children  thrive  on  it.  More,  however,  appear  only 
to  do  so,  for  increasing  weight  and  obesity  are  not  synony- 
mous with  health  and  strength.  A  better  way  to  dilute 
cow's  milk,  and  at  the  same  time  to  render  its  casein  less 
liable  to  coagulate  in  large  lumps,  is  the  addition  of 
decoctions  of  cereals.  Their  mechanical  effect,  however, 
is  not  the  only  one  which  is  obtained.  They  add  to  the 
nutritiousness  of  the  food  by  their  albuminoids,  and  are 
certainly  not  injurious  because  of  their  relative^  small 
percentage  of  starch,  for  from  the  very  first  month  of 
life  a  distinct  diastatic  effect  is  produced  by  the  oral  se- 
cretion; it  increases  with  every  month.  Even  infusions 
of  the   parotids,  prepared   at  different  times   after   death, 

farina  or  gruel  to  babies  of  five  months  and  older.  When  ten 
or  twelve  months  old,  a  piece  of  rare  beefsteak  every  day  to 
suck  on. 

No  child  under  two  years  ought  to  eat  from  your  table. 

Summer   complaint: 

When  babies  throw  off  and  purge,  give  nothing  to  eat  and  noth- 
ing to  drink  for  at  least  four  or  six  hours.  A-fter  that  you  give 
a  few  drops  of  whiskey  in  a  teaspoonful  of  ice  water  now  and 
then,  but  no  more  until  you  have  seen  the  doctor. 

Stop  -giving  milk  at  once. 

Give  no  laudanum,  no  paregoric,  no  soothing  syrups,  no  teas. 

When  you  see  the  doctor,  trust  in  him  and  not  in  the  women. 
They  do  not  know  better  than  you  do  yourself. 

272 


CHOLERA    INFANTUM 

produce  the  same  effect.  Infusions,  however,  of  the  pan- 
creas taken  from  the  bodies  of  infants  who  have  lived  three 
weeks  produce  no  such  changes.  The  diastatic  power  of 
the  pancreas  begins  with  the  fourth  week  only,  and  re- 
mains feeble  up  to  the  end  of  the  first  year.  Kriiger 
(1891)  found  in  the  foetus  of  seven  months  a  sugar- form- 
ing ferment  which  increases  towards  the  normal  end  of 
intrauterine  life,  is  still  small  in  quantity  at  birth,  but  then 
grows  so  rapidly  that  it  is  as  active  about  the  eleventh 
month  of  life  as  it  is  in  the  adult. 

Zweifel  experimented  with  infusions  of  different  glands. 
That  of  the  submaxillary  glands  of  an  infant  did  not 
transform  starch  into  sugar,  even  after  the  lapse  of  a  whole 
hour.  The  effect  of  an  infusion  of  the  parotid  of  a  baby 
seven  days  old  was  distinct  after  four  minutes;  however, 
that  of  the  parotid  of  a  baby  who  had  died  at  the  age  of 
eighteen  days,  of  gastroenteritis,  did  not  act  until  the 
lapse  of  three-quarters  of  an  hour.  Nor  was  a  diastatic 
result  obtained  by  a  similar  infusion  made  of  the  parotids 
of  a  baby  prematurely  born,  and  of  one  who  died  of  diar- 
rhoea and  debility. 

In  the  healthy  baby,  however,  that  diastatic  effect  is  not 
absent.  In  connection  with  this  fact  it  is  also  important 
to  know  that  the  effect  produced  by  saliva  persists  in  the 
stomach  for  a  period  of  from  one-half  to  two  hours. 
But  this  ceases,  and  starch  will  no  longer  be  changed  into 
grape-sugar  inside  the  stomach,  as  soon  as  the  secretion 
of  hydrochloric  acid  has  begun  in  the  digestive  process. 
This  is  a  very  important  fact,  because  it  shows  that  the 
farinaceous  food  of  the  infant  or  child,  though  it  be  not 
masticated  and  pass  the  mouth  very  rapidly,  is  in  the 
stomach  still  under  the  influence  of  the  saliva.  For  hydro- 
chloric acid  is  not  secreted  at  once.  The  first  acids  in  the 
stomach  while  digestion  is  going  on  are  organic,  mostly 
lactic.  This  is  found  to  be  contained  in  that  organ  when 
gastric  juice  is  removed  from  it  in  the  first  period  of 
digestion.  Thus  in  a  gastrostomized  boy  Uffelmann  found 
under  normal  circumstances,  during  the  first  half-hour, 
lactic  acid  only;  afterwards  hydrochloric  acid.  The  latter 
is  not  met  with  during  fevers  of  any  kind,  provided  the 

273 


DR.    JACOBI'S    WORKS 

temperature  is  high,  nor  during  a  severe  gastric  catarrh 
(nor  in  dilatation  of  the  stomach  resulting  from  congenital 
or  other  constriction  of  the  pylorus).  In  these  conditions 
farinacea  (amylacea)  are  taken  to  advantage,  principally 
because  the  diastatic  effect  of  saliva  is  not  disturbed. 

In  anaemia  and  in  convalescence,  particularly  from  fevers, 
the  functions  of  the  stomach  are  impaired.  In  them  both 
pepsin  and  hydrochloric  acid  are  wanting.  To  increase 
their  secretion  large  quantities  of  water  are  required. 

Infants'  food  ought  to  be  mixed  with  large  quantities 
of  water,  not  for  the  sick  only,  but  under  ordinary  cir- 
cumstances. In  diseased  conditions  of  the  stomach  the  free 
dilution  of  children's  nourishment  with  water  is  demanded 
upon  the  following  additional  facts.  Only  to  a  certain 
limit,  if  at  all,  will  pepsin  be  furnished  for  digestive 
purposes.  Probably  a  portion  of  this  is  not  entirely  util- 
ized, because  a  great  quantity  of  water  is  necessary  to 
assist  in  pepsin  digestion.  In  artificial  digestion  albumin 
often  remains  unchanged  until  large  quantities  of  acidu- 
lated water  are  supplied.  Without  doubt  many  disturb- 
ances of  digestion  are  to  be  explained  by  a  deficiency  of 
water,  certainly  many  more  than  are  due  to  an  excess  of 
it,  for  the  latter  is  speedily  relieved  by  rapid  absorption. 

When  metamorphosis  is  generally  slow,  water  in  abund- 
ance increases  the  elimination  of  urea  and  carbonic  acid. 
When  the  urine  is  scanty  and  of  too  high  specific  gravity, 
water  protects  the  kidneys  from  undue  irritation.  It  acts 
on  the  mucous  membranes  as  it  does  on  the  external  in- 
teguments. In  laryngitis  and  bronchitis  it  liquefies  viscid 
expectoration;  in  many  forms  of  constipation  it  acts  bene- 
fically  by  increasing  the  secretion  of  the  muciparous  glands 
of  the  intestines.  Ice  and  ice-water,  or  iced  carbonated 
water,  in  small  quantities,  but  frequent  doses,  relieve  hyper- 
aesthesia  of  the  stomach  and  stop  vomiting.  Another  regu- 
lar addition  to  the  milk  food  of  infants  and  children  should 
be  that  of  sugar.  Its  percentage  in  the  milk  of  the  woman 
is  larger  than  in  that  of  the  cow.  Immediately  after  the 
milking  of  the  cow  the  milk-sugar  begins  to  be  changed 
into  lactic  acid.  This  process,  after  the  rennet  of  the 
stomach  has   exerted   its   coagulating   effect,  together   with 

274. 


CHOLERA    INFANTUM 

the  gradual  conversion  of  fat  into  acid,  is  the  final  cause 
of  curdling.  The  large  amount  of  sugar  in  woman's  milk, 
together  with  its  smaller  percentage  of  casein  (about 
one  per  cent.)  and  butter,  gives  it  the  peculiar  bluish 
color  and  gives  to  the  colostrum  of  the  first  days  after 
birth  (it  contains  plenty  of  salts  besides),  its  tendency  to 
loosen  the  bowels.  This  property  becomes  manifest,  some- 
times under  abnormal  circumstances.  Thus  in  the  milk  of 
anaemic  women  sugar  is  occasionally  found  to  an  unusual 
degree.  In  their  cases  the  other  solid  matters  may  also 
be  diminished,  still  this  is  not  uniformly  so.  The  infants, 
however,  suffer  often  from  obstinate  diarrhoea. 

The  conversion  of  milk-sugar  into  lactic  acid  takes 
place  very  rapidly  Under  its  influence  cow's  milk  turns 
sour  at  once.  Not  infrequently  is  it  acid  from  the  first; 
it  has  been  found  to  be  so  in  the  udder;  in  most  cases  it 
is  "  amphoteric,"  neutral.  Thus  the  question  arises  what 
kind  of  sugar  is  to  be  used  as  the  addition  to  the  food  of 
children  both  well  and  sick. 

Cane-sugar  is  not  so  easily  transformed.  Indeed,  it  is 
utilized  for  the  purpose  of  counteracting  the  rapid  con- 
version of  milk-sugar,  and  for  the  preservation  of  articles 
of  food  in  general.  Trade  is  not  so  slow  in  availing  itself 
of  the  results  of  organic  chemistry  as  the  medical  profes- 
sion. Condensed  milk  remains  unchanged  a  long  time, 
on  account  of  the  plentiful  addition  of  cane-sugar,  in  spite 
of  the  original  presence  of  milk-sugar  in  it.  Therefore  it 
is  not  at  all  an  indifferent  matter  whether  milk-sugar  or 
cane-sugar  be  added  to  the  food  of  infants  and  children. 
I  have  always  insisted  upon  the  selection  of  the  latter  for 
that  purpose.  Biedert  employs  cane-sugar  in  his  cream 
mixture. 

In  the  sick  the  absorption  of  sugar  is  slower  than  in 
the  healthy.  Besides,  during  most  diseases,  particularly 
those  of  the  alimentary  canal,  there  is  more  abnormal  fer- 
ment in  the  mouth  and  stomach.  Thus  but  little  sugar 
ought  to  be  given,  and  never  in  a  concentrated  form. 
Grape-sugar  and  dextrin  are  absorbed  equally.  Cane-sugar, 
according  to  Pavy,  is  partly  inverted  into  grape-sugar  and 
partly  absorbed.     All  appear  to  be   changed,  when  given 

275 


DR.    JACOBI'S    WORKS 

in  moderate  quantities,  into  carbonic  acid  and  water,  even 
during  slight  fever. 

In  that  form  of  constipation  of  small  infants  which  de- 
pends on  a  relative  absence  of  sugar  and  superabundance 
of  casein  in  the  breast-milk,  the  addition  of  sugar  acts 
very  favorably.  A  piece  of  loaf  sugar  (a  teaspoonful  or 
less)  dissolved  in  tepid  water  (or  oatmeal  water)  should 
be  given  before  each  nursing,  and  will  often  prove  the 
only  remedy  required  for  the  regulation  of  the  bowels. 

The  physiological  effect  of  chloride  of  sodium  is  very 
important,  no  matter  whether  it  is  directly  introduced 
through  the  mother's  milk,  or  added  as  a  condiment  to 
cow's  milk,  or  to  vegetable  food.  Both  of  the  latter  con- 
tain more  potassium  than  sodium,  and  neither  ought  ever 
to  be  given,  to  the  well  or  sick,  without  the  addition  of 
table  salt.  A  portion  of  that  which  is  introduced  may  be 
absorbed  in  solution;  another  part  is,  however,  broken  up 
into  another  sodium  salt  and  hydrochloric  acid.  Thus  it 
serves  directly  as  an  excitant  to  the  secretion  of  the  glands 
and  facilitates  digestion.  Therefore  during  diseases  in 
which  the  secretion  of  gastric  juice  is  interfered  with,  or 
in  the  beginning  of  convalescence,  when  both  the  secreting 
faculties  and  the  muscular  power  of  the  stomach  are  want- 
ing, and  the  necessity  of  resorting  to  nitrogenous  food  is 
apparent,  an  ample  supply  of  salt  ought  to  be  furnished. 
The  excess  of  acid  which  may  get  into  the  intestinal  canal 
unites  with  the  sodium  of  the  bile  in  the  duodenum,  and 
assists  in  producing  a  second  combination  of  chloride  of 
sodium,  which  again  is  dissolved  in  the  intestines  and  ab- 
sorbed. Its  action  in  the  circulation  is  well  understood; 
it  enhances  the  vital  processes,  mainly  by  accelerating  tis- 
sue changes  through  the  elimination  of  more  urea  and  car- 
bonic acid. 

A  very  important  fact  is  also  this:  that  the  addition  of 
chloride  of  sodium  prevents  the  too  solid  coagulation  of 
milk  by  either  rennet  or  gastric  juice.  Thus  cow's  milk 
ought  never  to  be  given  without  table  salt,  and  the  latter 
ought  to  be  added  to  woman's  milk  when  it  behaves  like 
cow's  milk  in  regard  to  solid  curdling  and  consequent 
indigestibility. 

276 


CHOLERA    INFANTUM 

Habitual  constipation  of  children  is  also  influenced  bene- 
ficially^  for  two  reasons:  not  only  is  the  food  made  more 
digestible,  but  the  secretions  of  the  alimentary  canal,  both 
serous  and  glandular,  are  made  more  effective  by  the  pres- 
ence of  sodium  chloride. 

A  certain  amount  of  fat  is  digested  even  in  fevers  of 
moderate  severity,  thus  also  in  typhoid  fever.  But  it  is 
a  good  rule  rather  to  reduce  its  quantity,  because  when  in- 
fants were  fed  on  cow's  milk  during  capillary  bronchitis, 
the  fat  in  the  faeces  was  known  to  amount  to  forty  per 
cent,  of  the  solid  constituents.  A  few  additional  remarks 
will  render  the  subject  clearer,  and  show  that  it  is  very 
easy  to  give  too  much  fat. 

Infant  faeces  are  comparatively  copious,  although  the 
baby  receives  absolutely  nothing  but  mother's  milk.  What 
has  been  called  detritus  in  the  faeces  is  not  exclusively  un- 
digested casein,  but  principally  fat  and  large  masses  of 
intestinal  epithelium.  This  so-called  detritus  is  not  soluble 
in  water,  acids,  or  alkalies,  but  quite  soluble  in  alcohol 
and  ether.  Casein  is  also  present  when  it  has  been  taken 
in  too  large  quantity,  or  when  there  is  too  much  free  acid 
in  the  stomach.  In  those  cases  there  are  large  quantities 
of  it  in  the  faeces. 

An  important  practical  application  of  this  fact  is  the 
following:  As  it  is  true  that  fat  is  not  completely  ab- 
sorbed, even  under  the  most  normal  circumstances;  as  free 
fat  acids  are  so  easily  formed  and  accumulated;  as  they  are 
found  in  moderate  quantities,  even  in  healthy  babies;  as 
a  surplus  is  very  apt  to  derange  digestion  and  assimilation, 
and  to  prevent  the  normal  secretion  of  either  of  the  diges- 
tive fluids;  as  there  is  a  superabundance  of  fat  in  the  nor- 
mal food  of  the  nursling,  the  conclusion  is  justified  that  we 
should  be  very  careful  in  preparing  foods  for  the  healthy 
or  sick.  It  is  very  easy  to  give  too  much  fat.  It  is  hardly 
probable  that  there  is  too  little.  The  subject  of  "fat 
diarrhoea,"  which  depends  on  the  excess  of  fat  in  infant 
food,  has  been  discussed  on  page  266.  It  is  also  well 
illustrated  by  the  observations  of  V.  and  I.  S.  Adriance." 
They  have  succeeded  in  proving,  by  exact  chemical  and 
clinical  researches,  some  facts  which  were  known,  but  per- 

277 


JACOBI'S    WORKS 

haps  not  sufficiently  appreciated.  Both  excessive  fats  and 
proteids  in  the  milk  of  the  mother  may  cause  gastrointes- 
tinal symptoms  in  the  nursing  infant;  the  former  may  be 
reduced  by  diminishing  the  nitrogenous  elements  in  the 
mother's  diet;  the  latter  by  the  proper  amount  of  exercise. 
Excessive  proteids  are  especially  apt  to  cause  gastrointes- 
tinal symptoms  during  the  colostrum  period,  and  particu- 
larly during  that  of  premature  confinement,  when  their  per- 
centage is  higher.  Premature  infants  are,  therefore,  in 
particularly  great  danger,  and  their  food  ought  to  be 
greatly  modified  and  watered. 

In  connection  with  this  question  I  may  also  be  permitted 
to 'allude  to  the  indiscriminate  administration  of  cream  and 
the  routine  treatment  with  cod-liver  oil  in  case  of  sick- 
ness; even  normal  digestion  disposes  only  of  a  limited 
quantity  of  fat  (cream,  butter,  cod-liver  oil)  ;  twenty-five 
per  cent,  of  it  in  the  food,  as  lately  recommended,^"  is 
excessive.  One  of  the  preparatory  stages  of  its  assimila- 
tion is  the  formation  of  oleic  acid;  lipanin,  which  has 
been  recommended  in  place  of  cod-liver  oil,  contains  six 
per  cent,  of  that  acid,  the  physiological  preparation  of 
which  the  body  is  spared  by  its  administration.  There  may 
be  very  few  conditions  in  which  the  digestion  is  so  slow 
as  not  to  insure  some  of  the  required  transformation,  but 
in  chronic  dyspepsia  of  different  sorts  fat  is  badly  di- 
gested and  absorbed,  and  lipanin  may  take  its  place.  A 
small  amount  of  starch  is  digested  at  the  very  earliest  age. 
But  cereals  containing  a  small  percentage  of  it  only  are 
to  be  preferred.  Barley  and  oatmeal  have  an  almost 
equal  chemical  composition;  but  the  latter  has  a  greater 
tendency  to  loosen  the  bowels.  Thus,  where  there  is  a 
tendency  to  diarrhoea,  barley  ought  to  be  preferred;  in 
cases  of  constipation,  oatmeal.  The  whole  barley  corn, 
ground  for  the  purpose,  should  be  used  for  small  children, 
not  only  the  center  (which  is  preferred  because  of  its 
white  color),  because  of  the  protein  being  mostly  con- 
tained just  inside  and  near  the  husk.  The  newborn 
otight  to  have  its  boiled  milk  (sugared  and  salted)  mixed 
with  four  or  five  times  its  quantity  of  barley  water,  the 
baby  of  six  months  may  take  them  in  equal  parts.     Gum 

278 


CHOLERA    INFANTUM 

arable  and  gelatin  may  also  be  utilized  in  a  similar  manner. 
They  are  not  only  diluents,  but  also,  under  the  influence 
of  hydrochloric  acid,  nutrients.  Thus,  in  acute  and  de- 
bilitating diseases  which  furnish  no  or  little  hydrochloric 
acid  in  the  gastric  secretion,  a  small  quantity  of  the  latter, 
well  diluted,  should  be  provided  for. 

This,  my  method  of  infant  feeding,  which  is  suited  for 
the  stomachs  and  purses  of  the  rich  and  poor  alike,  is, 
however,  not  the  only  one  proposed  and  found  satisfactory. 
No  single  method,  indeed,  is  the  only  one,  nor  does  it  suit 
every  case.  It  is  only  an  occasional  chemist  who  expects 
the  organic  stomach  to  behave  like  a  chemical  reagent; 
clinicians,  however,  admit  exceptions  to  the  working  of 
their  rules  and  regulations,  though  their  conception  were 
ever  so  correct  and  physiological.  Still  the  endeavors  to 
improve  the  diet  of  the  young,  and  thereby  to  remove 
the  dangers  of  intestinal  disorders  and  the  sources  of  ex- 
cessive mortality  and  invalidism,  are  going  on.  Nothing 
has  been  more  successful  in  that  direction  than  the  wide- 
spread practice  of  sterilization  and  pasteurization  of  cow's 
milk.  Both  are  the  logical  development  of  the  plan  of 
treating  milk  by  boiling  which  I  have  persistently  advised 
these  forty  years  at  least,  and  detailed  in  my  "  Infant 
Diet "  ^^  in  Gerhardt's  "  Handbuch,"  ^^  in  Buck's  "  Hy- 
giene," ^^  in  "  Intestinal  Diseases  of  Infancy  and  Child- 
hood," ^*  and  in  my  clinical  lectures  delivered  during  more 
than  one-third  of  a  century.  There  can  hardly  be  a  doubt 
that  if  raw  milk  could  always  be  had  unadulterated,  fresh, 
and  untainted,  and  as  often  as  it  were  wanted,  it  would 
require  no  boiling.  It  would  even  contraindicate  it,  for 
high  temperatures  destroy  not  only  some  of  the  dangerous 
bacteria,  but  also  those  whose  action  is  desirable  for  nor- 
mal digestion.  Besides,  there  are  those  who  strongly  be- 
lieve that  boiling  causes  chemical  changes.  But  such  ideal 
milk  cannot  be  had  so  long  as  cows  are  tuberculous,  as 
scarlet  fever  and  diphtheria  are  met  with  in  the  houses 
and  about  the  clothing  and  on  the  hands  of  dairy  men  and 
women,  and  as  typhoid  stools  are  mixed  with  the  water 
which  is  used  for  washing  utensils. 

Now,  what  is  it  that  boiling  can  and  will  do?     Besides 

279 


DR.    JACOBI'S    WORKS 

expelling  air,  it  destroys  the  germs  of  typhoid  fever, 
Asiatic  cholera,  diphtheria,  and  tuberculosis,  also  the  oidium 
lactis,  which  is  the  cause  of  the  change  of  milk-sugar  into 
lactic  acid  and  of  the  rapid  acidulation  of  milk  with  its 
bad  effects  on  the  secretion  of  the  intestinal  tract.  Some 
varieties  of  proteus  and  most  of  bacterium  coli  are  also 
rendered  innocuous  by  boiling.  Thus  it  prevents  many 
cases  of  infant  diarrhoea  and  vomiting,  but  not  all  of  them, 
for  the  most  dangerous  bacteria  are  influenced  neither  by 
plain  boiling  nor  by  the  common  methods  of  sterilization. 
Boiling,  or  sterilization,  is  not,  however,  a  safe  protection 
under  all  circumstances.  Aerobic  bacteria,  the  so-called 
hay  or  potato  bacilli,  have  very  resistant  spores,  which 
develop  in  time.  They  are  found  in  cow-dung  and  in  the 
dust  of  stables,  of  the  soil  and  streets,  and  of  hay;  they 
render  the  milk  alkaline  and  bitter;  they  peptonize  casein 
and  liquefy  it  and  make  the  milk  still  more  bitter.  They 
are  very  poisonous;  their  pure  culture  gives  young  dogs 
a  fatal  diarrhoea.  It  takes  hours  of  sterilization  to  kill 
them;  in  some  instances  it  required  five  or  six  hours. 
Even  the  bacillus  butyricus  takes  an  hour  and  a  half. 
But  such  a  protracted  sterilization,  besides  being  far  from 
certain  in  its  effect,  is  a  clumsy  procedure  and  one  not  cal- 
culated to  benefit  the  milk.  That  is  why  hay-feeding  is  an 
absolute  necessity,  for  the  bacilli  are  destroyed  by  a  six 
weeks'  drying.  Besides,  it  is  important  to  keep  the  stables 
scrupulously  clean,  to  avoid  dirt  and  dust,  to  employ  peat 
instead  of  straw  for  bedding,  to  wash  the  udder  and  tie 
the  tails  before  milking,  to  throw  away  the  first  milk,  and 
to  remove  foreign  material  from  the  milk  by  the  centrif- 
ugal machine.  But  no  absolute  security  can  be  guaranteed. 
Therefore  Fliigge  adds  to  his  expositions  a  warning  against 
some  wholesale  manufacturers  who,  always  anxious  about 
somebody's — their  own — welfare,  were  (are?)  known  to 
conceal  the  changed  condition  of  the  milk  and  the  separa- 
tion of  butter  particles  by  coloring  the  glass  of  their 
bottles. 

Whatever  I  have  here  brought  forward  is  certainly  not 
to  disparage  the  boiling  of  the  milk;  it  is  meant  to  prove 
the   danger   of   relying    on   a   single   preventive   when   the 

280 


CHOLERA    INFANTUM 

causes  of  intestinal  disorders  are  so  many  It  is  true,  how- 
ever, that  the  large  majority  of  the  latter  depend  on  causes 
which  may  be  met  by  sterilization,  but  not  by  sterilization 
only;  also  by  pasteurization, — that  is,  heating  the  milk  to 
70°  C.  (165°  F.),  and  keeping  it  at  that  temperature  for 
thirty  minutes — a  procedure  which  destroys  the  same  germs 
that  are  killed  by  a  more  elevated  temperature  without 
much  change  in  the  flavor  and  taste  of  the  milk.  Pasteur- 
ization, however,  is  rejected  by  H.  Koplik. 

One  of  the  questions  connected  with  the  employment  of 
sterilized  or  pasteurized  milk  is  whether  the  milk  to  be 
used  for  a  child  ought  to  be  prepared  at  home,  or  whether 
the  supply  may  be  procured  from  an  establishment  where 
large  quantities  of  milk  believed  to  become  immutable  for 
an  indefinite  period  by  sterilization  are  kept  for  sale.  In 
regard  to  this  problem,  Fliigge  plaintively  expresses  his 
regrets  that  "  we  have  allowed  ourselves  to  be  guided  by 
people  who  are  neither  hygienists  nor  physicians,  but  chem- 
ists, farmers,  or  apothecaries,  and  whose  actions  have  been 
based  on  three  false  beliefs.  Of  these  the  first  is  that  boil- 
ing for  three-quarters  of  an  hour  destroys  germs;  the  sec- 
ond, that  whatever  bacteria  remain  undestroyed  are  innocu- 
ous ;  and  the  third,  that  proliferating  bacteria  can  always  be 
recognized  by  symptoms  of  decomposition."  Nothing  is 
more  erroneous.  Soxhlet  himself,  the  German  originator 
of  sterilization,  knew  at  an  early  period  that  the  fer- 
menting process  is  now  and  then  but  partially  interrupted 
by  boiling,  that  butyric  acid  may  be  found  in  place  of 
lactic  acid,  that  a  strong  evolution  of  gas  may  be  caused 
after  such  boiling,  and  that  such  milk  may  give  rise  to 
flatulency.  Indeed,  milk  which  happens  to  contain  the 
resistant  spores  of  bacteria  becomes  a  better  breeding- 
ground  for  them  by  the  very  elimination  of  lactic  acid, 
and  the  longer  such  sterilized  milk  is  preserved  and  off'ered 
for  sale  the  worse  is  its  condition.  It  may  be  true  that 
these  conditions  are  not  met  with  very  frequently,  but 
an  occasional  single  death  caused  by  poisonous  milk  will 
be  more  than  enough.  Therefore,  the  daily  home  steriliza- 
tion is  by  far  preferable  to  the  risky  purchase  from  whole- 
sale  manufacturers  who   cannot  guarantee  because  in  the 

281 


DR.    JACOBI'S    WORKS 

nature  of  things  they  cannot  know  the  condition  of  their 
wares. 

Another  alteration  of  a  less  dangerous  character,  but  far 
from  being  desirable,  is  the  spontaneous  separation  of 
cream  from  sterilized  milk  which  is  preserved  for  sale. 
Renk^^  found  that  it  took  place  to  a  slight  extent  during 
the  first  weeks,  but  later  to  such  a  degree  that  43.5  per 
cent,  of  all  the  cream  contained  in  the  milk  was  eliminated. 

Sterilization  has  been  claimed  to  be  no  unmixed  boon 
because  of  its  changing  the  chemical  constitution  of  milk. 
Still,  opinions  on  that  subject  vary  to  a  great  extent,  the 
occurrence  of  changes  being  both  asserted  and  denied  by 
apparently  competent  judges.  But  what  I  have  said  a 
hundred  times  is  still  true  and  borne  out  by  facts — viz., 
that  no  matter  how  beneficial  boiling,  or  sterilization,  or 
pasteurization  may  be,  it  cannot  transform  cow's  milk  into 
woman's  milk,  and  that  it  is  a  mistake  to  believe  that  the 
former,  by  mere  sterilization,  is  a  full  substitute  for  the 
latter.  It  is  true  that  when  we  cannot  have  woman's 
milk  we  cannot  do  without  cow's  milk.  There  is  no  al- 
leged substitute  that  can  be  had  with  equal  facility  or  in 
sufficient  quantity.  But,  after  all,  it  is  not  woman's  milk. 
Babies  may  not  succumb  by  using  it,  and  may  but  seldom 
appear  to  suffer  from  it ;  indeed,  they  will  mostly  appear  to 
thrive  on  it;  but  it  is  a  makeshift  after  all  and  requires 
modifications.  Hammarsten  was  the  first  to  prove  the 
chemical  difference  between  the  casein  of  cow's  and  wo- 
man's milk.  Whatever  was  known  on  this  subject  at  that 
time  I  collated  in  Gerhardt's  "  Handbuch."^-  The  casein 
of  woman's  milk  is  not  so  easily  thrown  out  by  acids  or 
salts  as  that  of  cow's  milk,  and  is  more  readily  dissolved 
in  an  excess  of  acid.  But  lately  Wroblewski  demonstrated 
the  difference  in  solubility  of  the  two  milks.  Woman's 
casein  retains,  during  pepsin  digestion,  its  nuclein  (pro- 
teid  rich  in  phosphorus)  in  solution,  it  is  fully  digested; 
in  cow's  casein  the  nuclein  is  not  fully  digested,  a  "  para- 
nuclein "  is  deposited  undissolved  and  undigested.  Be- 
sides, woman's  casein  contains  an  additional  albuminoid 
which  is  not  identical  with  either  the  known  casein  or 
albumin   (H.   Hoplik^®).     Of  the  albuminoids  in  woman's 

282 


CHOLERA    INFANTUM 

milk  sixty-three  per  cent,  is  casein,  thirty-seven  per  cent. 
lacto-albumin  (Schlossmann),  which  being  directly  absorb- 
able constitutes  an  essential  difference  from  cow's  milk; 
all  of  the  latter  has  to  be  transformed  during  the  digestive 
process  before  it  can  be  assimilated.  Besides,  there  is 
(Wroblewski)  in  the  human  milk  another  proteid  rich  in 
sulphur,  poor  in  hydrocarbon,  and,  according  to  several 
authors,  in  albumoses  and  peptones. 

K.  Wittmaack  and  M.  Siegfried  ^^  published  lately  their 
essays  on  nucleon  (the  phosphoric  acid  of  muscle)  in  the 
milks  of  cow,  woman,  and  goat,  and  on  phosphorus  in  the 
milks  of  the  cow  and  the  woman.  Their  conclusions  are 
accepted  by  E.  Salkowski  as  correct,  which,  I  should  say, 
proves  them  to  be  so.  Cow's  milk  contains  0.057,  goat's 
milk  0.110  and  woman's  milk  0.124  per  cent,  nucleon.  In 
cow's  milk  the  phosphorus  of  the  nucleon  amounts  to  six 
per  cent,  of  the  total  amount  of  phophorus  contained  in 
the  milk;  in  woman's  milk  41.5  per  cent.  That  means  that 
in  cow's  milk  not  one-half  of  its  phosphorus  is  in  the  or- 
ganic combinations  of  casein  and  nucleon;  in  woman's 
milk  almost  all  of  it  is.  In  cow's  milk  the  phosphorus  not 
utilized  for  organic  combinations  is  contained  in  the  inferior 
phosphates.  E.  Salkowski  adds  the  following  remarks: 
"  These  conditions  are  evidently  of  the  greatest  moment 
in  the  nutrition  of  the  nursling.  As  the  development  of 
bones  is  more  readily  accomplished  in  nurslings  fed  on 
woman's  milk  than  in  those  fed  on  cow's  milk,  the  probable 
conclusion  is  that  nucleon  has  an  important  part  in  the 
absorption  and  assimilation  of  phosphorus."  The  same 
should  be  said  of  calcium,  which  also  combines  with  nu- 
cleon. Though  woman's  milk  contains  less  calcium  than 
cow's  milk,  more  calcium  is  utilized  out  of  the  former,  and 
the  nucleon  is  evidently  an  important  factor  in  its  ab- 
sorption also. 

Ergo,  cow's  milk  is  not  woman's  milk.  It  is  not  iden- 
tical with  it.  Sterilization  does  not  change  its  character; 
it  merely  obviates  such  dangers  as  result  from  the  pres- 
ence of  most  pathogenic  germs  and  from  premature  acid- 
ulation.  The  substitution  of  cow's  milk  or  of  sterilized 
cow's  milk  for  woman's  milk  as  the  exclusive  infant  food 

283 


DR.    JACOBFS    WORKS 

is  a  mistake.  Experience  teaches  that  digestive  disorders, 
such  as  constipation  or  diarrhoea,  and  constitutional  derange- 
ments, such  as  rachitis,  may  be  produced  by  its  persistent 
use,  and  it  appears  to  be  more  tlian  an  occasional  (at 
least  co-operative)    cause  of  scurvy. 

Since  the  advisability  of  finely  dividing  and  suspending 
the  casein  of  cow's  milk  and  of  adding  to  the  nutritiousness 
of  the  latter  caused  me  always  to  advise  the  admixture  of 
cereals  with  it,  even  in  the  very  first  days  of  infancy, 
the  subject  of  infant  feeding  has  never  been  lost  sight 
of  by  medical  men,  scientists,  and  tradesmen.  No  subject 
has  been  treated  more  extensively,  more  eagerly,  sometimes 
even  more  spitefully,  than  that  of  infant  feeding.  The 
philosopher's  stone  has  not  been  so  anxiously  sought  for 
nor  so  often  found  as  the  correct  infant  food  and  the 
appropriate  treatment  of  cow's  milk  in  medical  journals, 
books,   and  societies. 

The  debilitating  influence  of  persistent  summer  heat  may 
be  counterbalanced  by  improving  the  vitality  and  resisting 
power  of  the  young.  It  is  true  no  newborn  baby  should 
be  bathed  in  cold  water,  but  the  gradual  diminution  of  the 
temperature  of  the  water  used  for  ablutions  may  go  on 
until  after  a  few  weeks  or  months  the  healthy  infant 
bears  washing  and  friction  with  cold  water  perfectly  well. 
In  the  heat  of  summer  it  should  be  so  treated  several 
times  a  day.  The  clothing  should  be  quite  thin;  those 
who  perspire  freely  should  have  no  linen  next  to  their 
bodies;  altogether,  cotton  or  thin  flannel,  both  of  which 
gradually  absorb  and  give  off"  perspiration,  are  preferable. 
In  very  warm  weather  a  single  loose  gown  should  be  suf- 
ficient. No  feather  beds  or  pillows  should  be  permitted. 
Surely  the  baby  would  be  better  off*  in  a  hammock,  the 
head  being  supported  by  a  hair  or  air  pillow.  Babies  in 
bed  should  have  their  positions  changed  from  time  to 
time. 

The  mouth  of  the  newborn  infant  requires  the  utmost 
care.  It  is  a  frequent  inlet  of  microbes  and  toxins,  and 
when  its  mucous  membrane  is  injured,  it  adds  a  new  ele- 
ment of  danger  to  the  diff"erent  forms  of  intestinal  and 
septic  disturbances  which  are  not  at  all  uncommon  at  the 

284 


CHOLERA    INFANTUM 

earliest  age.  The  attempts  at  cleansing  the  mouth  may 
prove  dangerous.  All  the  integuments  of  the  newly-born 
are  in  a  condition  of  desquamation.  Clumsy  rubbing  with 
coarse  or  stained  cloths  by  the  fingers  of  a  nurse  or  doctor 
that  are  not  absolutely  aseptic,  is  a  direct  cause  of  infec- 
tion. Even  the  water  in  which  the  baby  is  bathed  may  add 
to  that  danger.  What  is  called  Bednar's  aphthae  is  nothing 
but  the  ulcerations  of  the  very  thin  mucous  membranes 
mainly  on  and  near  the  alveolar  processes;  these  heal 
but  slowly  and  complicate  every  disorder  of  an  infectious 
nature.  If  such  a  mouth  is  filled  with  sugar,  teas,  or  syrups 
of  questionable  composition,  the  consequences  are  often 
bad. 

Cow's  milk  will  always  be  one  of  the  foods  administered 
at  any  age.  In  the  country,  when  the  cattle  are  not  tubercu- 
lous, and  when  no  diphtheria,  scarlatina,  and  typhoid 
fever  can  vitiate  the  milk,  it  should  be  given  fresh,  modi- 
fied by  the  addition  of  barley  or  oatmeal  water.  City 
milk  is  no  longer  fresh.  In  many  medium-sized  European 
cities  milk  is  delivered  within  four  hours  after  milking 
(in  Frankfort,  for  instance,  since  1877);  in  New  York  it 
takes  from  ten  to  sixteen  hours  or  more.  No  such  milk, 
unchanged,  is  fit  for  the  use  of  young  infants.  Boiling, 
sterilization,  or  pasteurization  is  therefore  indispensable, 
partly  to  destroy  the  bacterium  aerogenes,  partly  to  render 
innocuous  such  pathogenous  germs  as  may  have  been  ad- 
mitted during  the  long' time  which  elapsed  between  milking 
and  consuming. 

Even  if  it  were  possible  to  compound  an  accurate  sub- 
stitute for  breast  milk,  this  has  the  advantage  of  its  free- 
dom from  pathogenous  germs,  and  of  its  changeability 
under  divers  circumstances.  Alterations  of  breast  milk 
depending  upon  moderate  changes  of  food  taken  by  the 
mother  or  wet-nurse  are  as  a  rule  not  hurtful;  its  dilution 
by  the  ample  quantities  of  water  taken  by  them  in  hot 
weather  is  a  direct  advantage  to  the  nursling.  The  same 
quantity  and  quality  of  food  is  not  equally  digestible  in 
summer  and  in  winter;  what  is  well  borne  and  demanded 
in  the  winter,  by  the  adult  or  by  the  young,  proves  an 
excess  in  summer.     "  Modified  milk,"   "  Gaertner's  milk," 


DR.    JACOBI'S    WORKS 

and  their  like  are  always  the  same,  day  in  and  day  out; 
breast  milk,  however,  may  change.  The  main  danger  at- 
tending the  uniformity  of  food  is,  in  hot  weather,  the  in- 
sufficient amount  of  water,  of  which  our  babies  do  not  re- 
ceive enough.  Casein,  sugar,  fat,  and  salts  should  not 
only  have  their  due  average  admixture  of  water,  but  the 
latter  should  be  given  in  extra  doses  during  hot  weather. 
Perspiration  thickens  the  blood,  hinders  the  circulation, 
and  may  even  lead  to  thromboses ;  it  is  good  practice, 
therefore,  to  give  breast-fed  children  a  drink  of  water — 
which  should  be  boiled  and  thereby  sterilized — before  each 
nursing;  and  to  dilute  the  artificial  food  given  to  those 
who  are  brought  up  on  the  bottle,  and  to  let  them  all 
have  water  between  meals  to  their  heart's  content. 


TREATMENT 

The  most  perceptible  symptoms  of  cholera  infantum  are 
vomiting  and  diarrhoea,  both  of  which  are  in  the  large 
majority  of  cases — to  say  the  least — the  effects  of  irrita- 
tion or  paralysis  caused  by  bacteria  and  toxalbumins. 
Whatever  is  still  within  reach  and  active,  should  be  re- 
moved by  irrigation.  If  there  is  reason  to  suppose  that 
the  stomach  still  contains  foreign  materials,  it  should 
be  washed  out,  no  matter  whether  the  attack  is  attended 
with  fever  or  not.  Both  bacteria  and  toxalbumins  may 
prove  fatal  without  much  increase  of  temperature;  indeed, 
many  attacks  of  cholera  infantum  behave  in  this  respect 
like  diphtheria,  puerperal  fever,  or  other  septic  processes, 
the  worst  forms  of  which  are  often  accompanied  with  low 
temperatures.  A  mouth  gag  is  not  always  required  for 
the  purpose  of  irrigating  the  stomach,  but  in  most  cases 
it  facilitates  the  procedure;  a  cork  firmly  planted  between 
the  alveolar  processes  will  generally  suffice  to  enable  the 
fingers  to  perform  their  work.  No  solid  stomach  tubes 
should  be  employed.  Soft  elastic  catheters,  Nos.  16  to 
SO  French,  according  to  age,  will  suffice.  The  baby, 
wrapped  up  in  a  blanket  and  sitting  on  the  lap  and  be- 
tween the  arms  of  an  attendant,  is  satisfactorily  immo- 
bilized, and  its  head  is  sufficiently  fixed  and  bent  forwards 

286 


CHOLERA    INFANTUM 

so  as  not  to  narrow  the  space  between  trachea  and  verte- 
bral column.  There  are  but  few  cases  in  which  the  oesoph- 
agus is  missed  at  the  first  attempt;  when  the  tube  has 
once  entered,  the  slight  contraction  behind  the  larynx  is 
easily  overcome,  and  the  catheter  slides  down.  By  means 
of  a  glass  tube  and  an  india-rubber  tube  attached  to  it, 
the  connection  with  a  funnel,  through  which  tepid  water 
is  slowly  poured  in,  is  easily  established.  The  flow  is 
graduated  by  the  elevation  of  the  funnel.  When  a  few 
ounces  have  been  allowed  to  fill  the  stomach,  the  funnel 
is  lowered  and  the  liquid  runs  out.  The  same  procedure 
is  repeated,  while  the  amount  of  liquid  is  increased,  until 
the  water  returns  clear.  Vomiting  alongside  the  tube  is  not 
harmful.  The  "  fountain  syringe  "  in  common  use  among 
us  will  answer  every  purpose.  In  individual  cases,  when 
the  indication  of  direct  disinfection  appears  urgent,  the 
tepid  water  (or  0.6  per  cent,  salt  solution)  may  contain 
resorcin  (one  per  cent.)  or  thymol  (.02  per  cent.)  or 
permanganate  of  potassium  (.02  per  cent.).  As  a  rule 
these  additions  will  not  be  required;  nor  is  the  irrigation 
of  the  stomach  indispensable  when  the  patient  is  seen  some 
time  after  the  vomiting  has  ceased.  In  bad  cases,  however, 
any  doubt  in  that  respect  should  be  dismissed  in  favor  of 
irrigation.     It  will  not  often  be  required  a  second  time. 

The  next  step  in  the  treatment  of  cholera  infantum  is 
the  washing  out  of  the  intestinal  tract  as  far  as  it  is  ac- 
cessible. The  fluid  to  be  introduced  is  the  same  as  above. 
In  a  number  of  instances  when  there  seemed  to  be  intense 
pain  or  tenesmus,  I  have  mixed  subcarbonate  or  subgallate 
of  bismuth  with  the  water.  The  baby  should  be  placed  on 
one  side,  the  nozzle  of  the  fountain  syringe  introduced  a 
few  inches,  and  the  instrument  suspended  a  foot  or  two 
over  the  anus.  To  facilitate  the  flow,  the  hips  should  be 
somewhat  raised;  in  some  instances  the  gentle  manipulation 
of  the  abdomen  answers  the  same  purpose.  To  introduce 
a  long  tube  in  order  to  reach  the  colon  is  either  unneces- 
sary or  contraindicated.  For  in  the  infant  the  sigmoid 
flexure  is  so  long  that  no  tube  passes  the  convolutions 
which  are  apt  to  cover  one  another,  and  sometimes  reach 
to  the  opposite  side  of  the  upper  pelvis.     When  the  tem- 

287 


DR.    JACOBI'S    WORKS 

perature  of  the  body  is  high,  the  injection  should  be  cool; 
when  there  is  collapse,  it  should  be  hot.  In  the  latter 
case,  a  small  amount  of  alcohol  (one  per  cent.)  or  good 
brandy  or  whiskey  (two  or  three  per  cent.),  or  coffee 
should  be  added  to  the  injection.  These  irrigations  should 
be  continued  until  the  fluid  returns  clear;  they  should  be 
repeated  when  the  diarrhoea  returns,  and  particularly  when 
the  stools  are  offensive.  That  all  the  injected  fluid  should 
be  expelled  is  not  necessary;  on  the  contrary,  as  the  loss 
of  organic  water  has  been  great,  and  some  of  the  dangers 
of  cholera  infantum  depend  on  that  very  loss,  it  is  de- 
sirable that  the  intestine  should  retain  and  absorb  some 
fluid.  That  loss  is  so  serious  indeed  that  the  introduction 
of  water  becomes  an  urgent  necessity.  To  fulfil  this  in- 
dication in  emergency  cases,  subcutaneous  infusions  of  salt 
water  (6:  1000),  with  or  without  the  addition  of  sodium 
carbonate  (10:  1000)  are  required.  The  water,  however, 
should  be  sterilized,  and  the  whole  procedure  must  be 
aseptic.  It  is  true  that  many  of  the  cases  which  indicate 
it  will  die;  but  it  is  not  the  infusion,  but  the  disease 
that  kills.  I  feel  certain  that  a  few  of  the  patients  I 
have  seen  the  last  half-dozen  years  were  thus  saved. 

In  connection  with  the  question  to  what  extent  disin- 
fectants added  to  the  irrigations  destroy  bacteria  or  other 
toxins,  I  should  state  here  that  this  effect  need  not  be  ac- 
complished and  still  salutary  action  may  be  obtained.  Many 
years  ago  Prudden  proved  that  a  one-twentieth  of  one 
per  cent,  solution  of  carbolic  acid  annihilates  the  action  of 
bacteria,  not  indeed  by  killing  but  by  paralyzing  them. 
To  prevent  them  from  evolving  toxins  is  as  beneficial  as 
to  destroy  them. 

The  same  remark  should  be  made  in  regard  to  those 
internal  remedies  which  appear  to  be  indicated,  mainly  in 
those  cases  which  owe  their  origin  to,  or  are  evolved  out 
of  any  of  the  forms  of  prodromal  enteritis  or  entercoli- 
tis,  for  the  purposes  of  disinfection.  Vaughan  believes 
that  much  harm  and  no  good  can  be  obtained  from  them, 
but  every  clinician  knows  that  the  eminent  bacteriologist 
is  mistaken.  It  is  true  that  calomel,  naphthol,  naphthalin, 
salol,  and  camphor  in  medicinal  doses  do  not  diminish  the 

288 


CHOLERA    INFANTUM 

number  of  bacteria  nor  even  of  saprophytes,  but  the  effect 
of  the  microbes  becomes  less  virulent. 

Constant  vomiting  forbids  the  introduction  of  food  or 
drink.  Whether  there  be  thirst  or  not,  the  patient  must 
be  starved.  While  he  is  so  deprived  his  thirst  will  de- 
crease rather  than  increase.  This  period  of  total  abstinence 
may  last  from  four  to  twelve  hours.  After  this  some  bear 
small  pieces  of  ice  quite  well;  but  to  begin  with  it  too 
early  excites  vomiting  and  peristalsis.  A  teaspoonful  of 
boiled  water,  cooled,  may  be  given  every  five  or  ten  minutes. 
That  may  be  alternated  with,  or  replaced  by  thin  and 
thoroughly  cooked  and  strained  barley  water.  It  is  un- 
irritating  and  well  borne.  What  a  critic^^  of  Pepper's 
text-book  says,  viz.,  that  "  thousands  of  children  are  killed 
by  the  injudicious"  (?)  "use  of  barley  water" — that 
this  is  "  a  popular  fallacy  "  and  "  merits  oblivion,"  is  a 
mistake  and  reads  like  a  huge  joke.  Later  on  egg  water 
may  be  given,  that  is  the  white  of  a  fresh  egg  beaten  up, 
and  finally  shaken  in  a  bottle  containing  150  or  200  c.c. 
of  barley  or  rice  water,  in  small  amounts. 

No  milk  must  be  given  at  this  stage;  no  sterilized  or 
pasteurized  milk,  no  breast  milk.  It  is  true  that  under 
ordinary  circumstances  milk  feeds  babies,  but  in  these  ex- 
traordinary circumstances  it  feeds  bacteria.  No  milk  must 
be  given,  if  it  take  a  week  or  more,  until  the  alvine  dis- 
charges begin  to  change,  and  are  no  longer  malodorous. 
Now  and  then  a  teaspoonful  of  a  mild  tea,  or  a  few  drops 
of  a  good  whiskey  in  barley  water  may  be  given  once  every 
five  or  ten  minutes,  or  at  longer  intervals.  A  mixture  which 
has  served  me  well  in  many  cases,  after  the  starvation 
period  had  passed  and  the  stomach  began  to  exhibit  some 
little  tolerance,  is  the  following:  One  hundred  and  fifty 
cubic  centimetres  of  barley  water,  the  white  of  one  egg, 
one  or  two  teaspoonfuls  of  whiskey,  some  salt  and  cane 
sugar  to  improve  the  taste.  Of  this  a  teaspoonful  is  ad- 
ministered every  five  or  ten  minutes. 

When  milk  is  to  be  fed  again  it  should  not  exceed  ten 
per  cent,  of  the  barley  water  with  which  it  is  to  be  mixed. 
To  prepare  it  with  hydrochloric  acid,  according  to  the 
prescription  of  Dr.  Rudisch  which  I  have  frequently  used 

289 


DR.    JACOBI'S    WORKS 

these  more  than  twenty-five  years,  will  often  be  found 
profitable.  The  method  is  to  mix  2  c.c.  of  dilute  hydro- 
chloric acid  with  a  pint  of  water  and  to  add  thereto  a 
quart  of  milk.  This  is  to  be  boiled.  If  ever  there  be 
coagulation,  it  merely  proves  that  the  acid  was  mistakenly 
used  in  excess. 

Internal  medicinal  treatment  is  mainly  indicated  in 
those  cases  which  developed  on  the  basis  of  a  dyspeptic, 
catarrhal,  or  follicular  enteritis.  As  irrigations  of  the 
rectum  act  on  the  lower  part  of  the  bowels  only,  the  small 
intestines  may  be  cleared  by  a  purgative.  If  castor  oil 
be  retained,  it  will  have  a  good  effect.  To  mix  it  with 
tincture  of  opium  is  unwise  at  that  stage  in  which  the 
emptying  of  the  tract  of  injurious  masses  is  the  main  indi- 
cation. Calomel  may  take  its  place,  and  will  be  well 
tolerated  in  frequent  (hourly)  doses  of  4  to  5  mgm.  (gr. 
Vis  to  /42)-  It  should  be  continued  imtil  the  stools  show 
its  effect,  which  they  will  do  though  the  remedy  remain 
in  the  mouth  and  be  there  absorbed  after  having  been 
transformed  into  a  mercurial  albuminate.  If  there  be  an 
excess  of  acid  (lactic,  acetic,  or  butyric)  in  the  stomach, 
calomel  should  be  combined  with  an  alkali,  mainly  chalk, 
the  carbonate  and  phosphate  of  which  have  the  additional 
advantage  of  forming  with  the  fat  an  insoluble  combina- 
tion which  acts  as  a  protective  cover  to  the  sore  mucous 
membrane.  Doses  of  from  5  to  10  cgm.  (gr.  i.-iss.)  may 
be  given  every  two  hours.  The  subnitrate,  the  subcar- 
bonate,  or  the  subgallate  of  bismuth  in  doses  every  two 
hours  of  from  15  to  100  mgm.  (gr.  :J-iss.)  acts  as  a  dis- 
infectant, partly  by  binding  sulphide  of  hydrogen,  and 
protects  the  sore  surfaces.  Salol  should  not  be  given  in 
larger  doses  than  from  3  to  15  cgm.  (gr.  ss.-iiss.),  re- 
sorcin  from  15  to  30  mgm.  (gr.  ^-^.).  These  are  prefer- 
able to  many  others  because  of  their  indifferent  taste. 
When  the  time  has  arrived  for  astringents,  nitrate  of 
silver  in  solution,  2  to  4  mgm.  (gr.  /^o'Mn)  ^^  ^  tea- 
spoonful  of  water,  or  gallic  acid  in  doses  of  from  5  to  15 
cgm.  (gr.  i.-iiss.),  or  tannalbin  or  tannigen,  in  doses  of 
from  3  to  12  cgm.  (gr.  ss.-ii.) — all  of  them  in  intervals  of 
two  hours — may  be  administered. 

290 


CHOLERA    INFANTUM 

Are  there  any  indications  for  opium^  or  is  it  totally 
contraindicated  ?  It  certainly  limits  secretion  and  hyper- 
acidity better  than  morphine  Its  effect  is  slower  than 
the  latter,  and  therefore  safer  and  local.  It  also  di- 
minishes hyperperistalsis ;  it  is,  through  its  effect  on  the 
sensitive  nerves  or  on  the  ganglia,  a  sedative,  and  an  in- 
hibitory agent  through  strengthening  the  splanchnic.  Fi- 
nally it  relieves  pain.  Thus  it  is  readily  seen  that  in  the 
incipient  stages  of  dyspeptic  and  stercoraceous  diarrhoeas  it 
finds  no  place,  but  when  the  bowels  are  emptied,  it  ful- 
fils its  indication  of  relieving  pain  and  hypersecretion  and 
of  stimulating — in  small  doses — the  heart.  Under  these 
conditions  a  baby  of  six  months  may  take  from  four  to 
ten  drops  of  the  camphorated  tincture  of  opium,  or  an 
equivalent,  every  two,  three,  or   four  hours. 

Great  sensitiveness  of  the  abdomen  may  also  be  relieved 
by  warm  fomentations,  with  water,  or  with  poultices. 
They  should  be  covered  with  oiled  silk,  or  an  india-rubber 
cloth  and  flannel.  Care  should  be  taken  lest  the  clothing 
and  bedding  get  moist.  Warm  bathing  may  occasionally 
take  their  place.  In  cases  of  collapse  the  temperature  of 
fomentations  or  baths  may  be  raised  a  little  beyond  the 
normal  temperature  of  the  blood.  When  there  is  great 
pain  combined  with  high  temperature  of  the  body,  cool 
applications  to  the  abdomen  are  indicated.  The  cloth 
wrung  out  of  cool  water,  secured  and  protected  as  above, 
should  be  changed  when  it  becomes  hot. 

Great  care  should  be  given  to  the  relief  of  the  ex- 
hausted and  paralytic  condition  of  the  patient.  There  are 
those  cases  which  require  stimulation  at  once.  It  is  in- 
dicated when  the  fontanelle  is  depressed  at  an  early  time, 
the  pulse  very  small  and  frequent  (150-220)  and  hardly 
perceptible  at  the  wrist,  and  the  complexion  ashy.  To 
rely  on  internal  stimulants  is  out  of  the  question;  there 
are,  however,  many  opportunities  for  subcutaneous  appli- 
cations of  the  salicylate  (or  benzoate)  of  sodiocaffeine, 
of  the  sulphate  of  strychnine,  of  camphor,  or  of  whiskey. 
The  first  may  be  employed  in  doses  of  from  three  to 
eight  drops  of  the  saturated  solution  (1:2),  the  second  in 
doses  of  from  0.5  to  1  mgm.   (gr.  K20"%o)j  the  third  in 

291 


DR.    JACOBI'S    WORKS 

doses  of  from  four  to  ten  drops  of  a  solution  of  four 
times  its  weight  of  sweet  almond  oil;  of  the  last  from 
fifteen  to  twenty-five  drops  may  be  injected.  All  of 
these  administrations  may  be  repeated  according  to  indi- 
cations. The  same  remedies  may  be  used  internally  if 
the  condition  of  the  stomach  permit.  The  very  best  stimu- 
lant is  Siberian  musk,  of  which  from  3  to  10  cgm.  (gr. 
ss.-iss.)  may  be  given  every  half -hour,  until  from  three 
to  six  doses  will  have  been  taken. 


BIBLIOGRAPHICAL,     REFERENCES 

1.  Biedl  und  Kraus:  Zeltschrift  fiir  Hygiene  und  Infektion- 
skrankheiten,  xxvi.,  p.  376,  1897. 

2.  Fischl  und  Heubner:  Zeltschrift  fiir  klinische  Medicin, 
xxix.,  1896. 

3.  Uhlenhuth:  Zeltschrift  fiir  Hygiene  und  Infektlonskrank- 
helten,  xxv.,  p.  476,  1897. 

4.  Booker:  Johns   Hopkins   Hospital   Reports,  vi.,   1896. 

5.  Meinert:  Medical  Annual,  1893. 

6.  Jacobl:  Medical  Record,  December  18,  1868. 

7.  Clarke   Miller:  American    Journal   of   Obstetrics,    1879. 

8.  Jacob!:  Therapeutics  of  Infancy  and  Childhood,  2d  ed., 
Philadelphia,  1898. 

9.  V.  and   I.  S.  Adriande:  Archives  of  Pediatrics,  1897. 

10.  Berliner  klinische  Wochenschrlft,  June  14,  1897. 

11.  Jacobl:  Infant  Diet,  New  York,  1874. 

12.  Jacobl:  Die  Pflege  und  Ernahrung  des  Klndes  in  Ger- 
hardt's  Handbuch  der  Kinderheilkunde,  vol.  1.,  1877  (2d  ed., 
1882). 

13.  Jacobl:  Infant  Hygiene  in  Buck's  Hygiene,  New  York, 
1883. 

14.  Jacobl:  Intestinal  Diseases  of  Infancy  and  Childhood, 
Detroit,  188'i. 

15.  Renk:  Archlv  fiir  Hygiene,  xvll.,  1893. 

16.  H.   Hopllk:  New  York  Medical  Journal,  April   13,   1895. 

17.  Wlttmaack  und  Siegfried:  Zeltschrift  fiir  physlologlsche 
Chemle,  xxU.,  1896-97. 

18.  Book  Review  in  The  American  Therapist,  June,  1894. 


292 


TYPHOID  FEVER  IN  THE  YOUNG 

The  literature  of  the  typhoid  fever  in  infancy  and  child- 
hood is  very  copious ;  that  of  the  last  twenty  years  is  not 
exactly  worthless;  indeed,  a  number  of  magazine  articles 
are  quite  valuable.  But  they  do  not  compare  with  the 
very  first  publications  on  the  subject  which  appeared  at  a 
time  when  typhoid  fever  had  not  long  been  recognized  as 
an  independent  morbid  entity.  Amongst  those  which  should 
be  read  to-day,  in  order  to  gather  almost  everything  con- 
nected with  the  subject,  with  the  exception  of  the  Diazo 
and  Widal  tests,  are  Tapin,  in  the  Jour,  des  Conn.  med. 
et  Chirurg.  of  1839,  who  explains  the  apparent  infre- 
quency  of  typhoid  fever  in  the  young  by  the  mildness  of 
most  cases;  F.  Rilliet,  De  la  fievre  typhoide  chez  les  en- 
fants,  Paris,  1840;  the  article  on  the  subject  in  Rilliet 
and  Barthez's  great  Handbook  in  1853;  Louis  and  Andral 
in  1841;  a  paper  of  A.  Baginsky  in  Virchow's  Arch.  Vol. 
49;  of  Henoch  in  the  Charite  Ann.  Vol.  II,  1877;  the 
thesis  of  Georges  Montmoullin,  1885  (Observations  sur  la 
fievre  typhoide  de  I'enfance),  and  the  article  of  C.  Ger- 
hardt  in  the  second  volume  of  his  great  "  Handbuch,"  an 
1877.  The  most  meritorious  of  all  the  contributions  to  the 
knowledge  of  our  subject,  however,  is  the  little  book  of 
Edmund  Friedrich,  Der  Abdominal  Typhus  der  Kinder, 
Dresden,  1856.  My  advice  to  all  modern  and  future  writers 
on  any  topic  connected  with  the  question  of  typhoid  in 
children  is  to  first  consult  the  102  pages  of  that  mono- 
graph, which  is  apt  to  teach  the  often  forgotten  lesson 
that  medicine  is  not  of  to-day  nor  of  yesterday;  that  there 
have  been  great  and  good  men  worth  knowing,  before  we 
were  born,  and  that  the  history  of  our  science  and  art  is 
sadly  neglected  amongst  us. 

Infection  and  Contagion. — The  opportunities  for  infec- 
tion or  for  contagion  are  the  same  for  the  young  and  for 
the  old.     The  bacillus  has  been  found  active  though  it  had 

293 


DR.    JACOBI'S    WORKS 

been  dry  for  months ;  in  the  soil  and  in  clothing  after 
one  or  two  months.  Into  water  and  into  the  soil  it  is 
introduced  with  typhoid  discharges  which  carry  contagion 
though  thej'  have  been  in  contact  with  putrid  material. 
This  experience  explains  isolated  cases  and  those  attribu- 
table to  the  influence  of  sewers  and  privies,  and  the  trans- 
mission through  the  atmosphere.  Flies  have  been  charged 
with  carrying  the  poison.  Infected  water  that  is  used  for 
drinking  or  for  washing  the  bottles  and  cases  in  which 
milk  is  kept,  is  responsible  for  hundreds  of  epidemics. 
Contagion  from  patient  to  patient  in  a  hospital  or  in  a 
tenement,  by  bedding,  by  the  hands  of  the  attendant,  by 
the  use  of  the  same  unwashed  thermometer  for  the  typhoid 
and  non-typhoid  are  surely  either  possibilities  or  facts. 
The  fetus  and  newly  born  may  obtain  their  typhoids 
through  the  blood  of  the  mothers ;  contagion  through  the 
milk  of  the  mother  is  not  improbable,  though  in  most  of 
such  instances  the  suspicion  may  be  directed  to  other 
sources  of  the  malady.  Small  infants  have  a  great  ad- 
vantage in  this  that  their  typhoids  are  not  frequently 
attended  with  characteristic  stools,  and  that  for  this  reason 
a  hospital  case  is  not  so  dangerous  to  its  neighbors-;  that 
they  are  not  roaming  about  the  floors  where  older  children 
pick  up  infection,  and  that  the  water  they  drink  or  eat 
is  almost  always  boiled.  The  latter  fact  alone  explains 
the  relative  absence  of  typhoid  fever  from  the  first  year  of 
life. 

SYMPTOMATOLOGY. 

Temperature. — The  severity  of  the  illness  need  not  cor- 
respond with  the  body  temperature.  A  girl  of  9  years, 
whose  case  is  reported  by  Gerloczy,  in  D.  Med.  JVoch., 
No.  15,  1892,  had  unconsciousness,  diarrhea,  very  frequent 
pulse,  universal  hyperesthesia,  roseola,  abscesses,  and  bron- 
chial catarrh,  and  got  well  after  thirty-nine  days.  During 
all  this  time  there  was  no  increase  of  her  body  temperature. 
It  appears  that  very  severe  cases  of  typhoid  fever  when 
exhibiting  bad  cerebral  sj'mptoms  are  liable  to  have  low 
temperatures  on  account  of  the  thorough  sepsis  prevailing. 
If  so,  the  prognosis  is  very  bad. 

29'k 


TYPHOID    FEVER    IN    THE    YOUNC 

Belei  Medvei  (Intern.  Klin.  Rundschau,  1891,  No.  35 
and  36)  observed  a  girl  of  12  years  that  was  taken  sick 
with  severe  headache,  restlessness,  chill,  pain  in  neck,  un- 
consciousness, miosis,  unequal  pupils,  rapid  respiration,  and 
a  temperature  for  four  days  from  36.8°  to  37.5°  C.  Then 
the  temperature  rose  and  the  typhoid  symptoms  of  spleen 
and  cecum,  and  diarrhea  made  their  appearance. 

This  absence  of  high  temperature  does  not  astonish  those 
who  see  a  good  deal  of  sepsis  and  of  sickness  complicated 
with  weak  heart.  Temperature  and  danger  need  not  cor- 
respond. The  very  feeble  are  not  as  a  rule  subject  to  high 
temperatures  any  more  than  the  very  old;  and  quite  often 
the  worst  cases  of  sepsis  are  those  which  exhibit  low  tem- 
peratures. That  is  a  fact  best  known  to  those  who  see 
much  diphtheria  or  much  puerperal  fever. 

Observations  of  high  temperatures  previous  to  the  ap- 
pearance and  recognition  of  the  symptoms  are  not  fre- 
quent. While  an  adult  would  be  about  his  work,  the  infant 
or  child  is  seldom  considered  sick  enough  to  claim  atten- 
tion and  attendance.  That  is  why  chilliness  and  chills  are 
readily  overlooked;  indeed,  the  latter  are  not  marked  as 
a  rule  in  any  illness  of  the  young.  The  rise  of  the  tempera- 
ture in  the  typhoid  of  the  young  is  mostly  gradual ;  it  is 
high  in  the  second  stage  with  slight  remissions  and  gradually 
falls  toward  the  end  of  the  disease.  This  rule,  if  it  can  be 
called  so,  is,  however,  subject  to  many  exceptions.  The 
temperature  of  small  infants  may  be  very  irregular,  is  in 
many  cases  rather  low  and  uniform,  in  others  high  with 
few  and  short  remissions.  Irregularities,  moreover,  often 
depend  on  complications.  After  all,  neither  those  are  al- 
ways right  who  consider  the  typhoid  of  the  nursling  and 
infant  as  a  uniform  severe  disease,  like  Baginsky  and 
Roemheld,  nor  those  who  make  light  of  it.  The  degree  of 
individual  infection,  and  the  nature  of  the  epidemic  are 
factors  that  have  to  be  considered. 

Complications  which  disturb  the  regularity  of  the  tem- 
perature curves  are,  for  instance,  otitis,  which  is  quite 
frequent.  In  connection  with  it  we  should  not  forget  that 
the  otitis  media  of  the  infant  need  not  terminate  in  per- 
foration of  the  drum  membrane;  for  the  pharyngeal  end" 

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DR.    JACOBI'S    WORKS 

of  the  Eustachian  tube  is  so  large  a  funnel  at  that  early 
age  as  to  permit  the  discharge  of  pus  from  the  middle 
ear.  An  occasional  complication  is  scarlatina;  in  the  last 
two  years  malaria  was  a  more  frequent  complication  of 
typhoid  than  I  have  ever  known  it  to  be.  Suppurating 
arthritis,  diphtheria  of  the  throat  or  of  the  vulva,  both 
bacillary  and  streptococcic,  are  detrimental  in  the  same 
way.  Constipation  is  also  an  occasional  cause  of  the  rise 
of  temperature;  the  regular  visiting  hours  of  hospitals, 
even  without  clandestine  feeding,  are  apt  to  increase  tem- 
peratures. Now  and  then  there  are  two  regular  daily 
curves.  That  is  another  reason  why  the  rectal  temperature 
should  be  taken  at  least  four  times  in  twenty-four  hours. 

Digestive  Organs. — The  condition  of  the  lips,  the  tongue 
and  the  mouth  may  depend  on  previous  catarrh,  angina,  or 
the  presence  of  adenoids ;  otherwise  on  the  severity  of  the 
typhoid,  and  exhibits  the  same  surface  changes  of  the 
epithelium  and  mucous  membranes  that  are  observed  in 
the  adult.  The  lips  are  frequently  dry,  the  tongue  mostly 
moist,  its  epithelium  accumulated  in  the  centre,  the  edges 
red,  or  the  whole  tongue  red  and  dry,  covered  with  dry 
epithelial  scabs,  torn  or  ulcerated.  Large  ulcerations  are 
mainly  noticed  during  unconsciousness,  smaller  ones  may 
be  quite  numerous  on  the  hard  and  soft  palate  in  every 
severe  case.  There  is  no  herpes.  The  throat  shows  angina, 
the  tonsils  are  swollen,  in  exceptional  cases  covered  with  a 
pseudomembrane  which  once,  in  a  boy  of  9  years,  continued 
through  the  whole  length  of  the  esophagus  to  below  the 
cardia.  In  bad  cases  of  older  children,  or  in  the  few  that 
occur  in  the  nursling  when  the  mouth  is  kept  open  because 
of  the  narrowness  in  the  naso-pharynx,  of  indolence  or 
unconsciousness,  thrush  is  met  with  as  it  is  in  the  worst 
cases  of  adult  typhoid,  or  in  moribund  phthisis.  Stomacace 
is  less  frequent,  noma  still  less  so;  the  latter  is  observed 
only  toward  the  end  of  the  illness,  or  during  apparent 
convalescence.  Fortunately,  during  nearly  fifty  years  I 
met  with  half  a  dozen  cases  only,  one  in  a  baby  of  8 
months,  one  in  a  girl  of  1 1  years,  all  fatal.  Baginsky, 
however,  reports  a  case  of  noma  that  recovered.  It  may 
be  added  that  noma  is  not  quite  so  frequent  after  typhoid 

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TYPHOID    FEVER    IN    THE    YOUNG 

fever  as  after  some  other  infectious  diseases,  prominent 
amongst  which  is  measles,  where  I  have  seen  at  least  a 
dozen  instances.  Parotitis  may  terminate  in  perforation, 
either  outward  or  through  the  external  ear.  An  abscess 
of  the  submaxillary  gland  I  have  seen  in  few  cases  only. 
Otitis  media  is  an  occasional  complication  originating  in 
pharyngeal  changes.  The  appetite  is  proportionate  to  the 
fever,  the  dry  mouth  and  the  degree  of  unconsciousness ; 
during  convalescence  the  hunger  is  great  and  conducive  to 
dangerous  mistakes  in  diet.  Vomiting  is  noticed  in  bad 
cases,  and  is  caused  by  the  condition  of  the  digestive  mu- 
cous membrane,  occasionally  by  meningitis,  and  sometimes 
by  accompanying  or  consecutive  nephritis. 

Diarrhea  is  a  frequent  symptom  in  typhoid  fever,  either 
before  its  apparent  outbreak,  or  in  the  first  week,  or  at  a 
later  period.  It  appears  to  be  of  a  catarrhal  nature,  in- 
duced probably  by  the  presence  of  bacilli  and  their  toxins. 
In  the  later  periods  of  the  disease  it  certainly  depends  on 
the  presence  of  ulcerations.  But  to  expect  diarrhea  as  a 
common  symptom  is  a  mistake  occasioned  by  the  statements 
of  many  European  books.  In  the  other  hemisphere  diarrhea 
appears  to  be  more  general  than  with  us.  I  think  we  miss 
it  in  one-half  of  our  cases. 

Even  the  assumption  that  where  there  are  ulcerations 
there  must  be  diarrhea  is  not  founded  on  uniform  facts. 
In  ward  28  of  Bellevue,  in  1877,  I  had  a  girl  of  11  years 
that  was  under  close  observation  during  her  typhoid  fever 
for  several  weeks.  The  case  was  one  of  unusual  severity 
— spleen,  lungs,  skin  and  nervous  system  yielding  the  usual 
symptoms ;  there  was  no  diarrhea  at  any  time.  She  died 
with  the  symptoms  of  perforation.  Perforation  caused  by 
one  of  the  typhoid  ulcerations  was  found  at  the  autopsy. 
Nor  is  this  the  only  case  of  the  same  description  in  my 
experience.  In  the  Proceedings  of  the  Pathological  So- 
ciety, twenty-five  years  ago,  there  is  mentioned  the  case 
of  a  man  who  died  in  my  service  in  Mount  Sinai,  also 
with  perforation  of  an  ulcerating  intestine,  with  no  previous 
looseness  of  the  bowels. 

Constipation  is  not  an  uncommon  symptom  in  the  begin- 
ning of  typhoid  fever  of  the  young,  though  diarrhea  may 

297 


DR.    JACOBrS    WORKS 

develop  toward  the  end  of  the  first  or  during  the  second 
week,  while,  on  the  other  hand,  diarrhea  may  be  observed 
among  the  prodromi  or  in  the  first  week,  and  be  replaced 
by  constipation. 

Almost  in  all  cases  of  typhoid,  in  the  young  and  in  the 
old,  intestinal  ulcerations  are  common.  But  exceptions  to 
this  rule  are  met  with. 

S.  Flexner  and  N.  M.  Harris  (Bull.  Johns  Hopkins 
Hospital,  December,  1897)  detail  the  case  of  a  man  of  68 
years  who  had  typhoid  fever  with  bacilli  in  many  organs, 
but  no  intestinal  lesions;  A.  G.  Nichols  and  C.  B.  Keenan 
(Montreal  M.  Jour.,  January,  1898)  one  with  positive  Wi- 
dal  test,  and  tumefied  spleen  and  mesenteric  lymph  nodes, 
and  no  intestinal  lesions;  E.  Hodenpj^l,  one  that  died  on  the 
seventeenth  day  of  illness  with  ulcerations  in  the  large  in- 
testine, but  none  in  the  small.  This  absence  of  intestinal 
lesions  is  rare  indeed  in  the  adult;  in  the  young,  mainly 
in  the  very  young,  it  seems  to  be  less  rare.  As  a  rule, 
it  may  be  stated  that  the  intestinal  tract  suffers  more  in 
advanced  age,  the  blood  more  in  the  early. 

According  to  Bryant  {Brit.  Med  Journal,  1899,  I-,  p- 
766)  fifteen  cases  of  typhoid  fever  are  known  to  have 
exhibited  no  intestinal  lesions.  His  case  was  that  of  a 
boy  of  1  year  and  9  months ;  it  occurred  in  a  family  in 
which  there  were  other  cases  of  typhoid  fever.  There  was 
a  characteristic  fever  curve,  diarrhea,  tympanites,  tumefac- 
tion of  the  spleen,  and  a  positive  Widal  reaction.  At  the 
autopsy  there  were  pure  cultures  of  bacilli  in  the  en- 
larged mesenteric  glands,  but  no  intestinal  ulceration. 

In  one  of  his  autopsies  Henoch  found  but  one  Peyer's 
plaque  that  was  slightly  swelled. 

In  N.  Y.  Med.  Journal  of  July  29th,  A.  J.  Hartigan, 
assistant  in  the  Bender  Laboratory  of  Albany,  N.  Y., 
reports  two  cases  of  typhoid  infection  without  any  intestinal 
lesions.  Of  the  older  literature  of  such  instances  he  quotes 
Louis,  more  than  half  a  century  ago,  and  Litten,  Moore, 
and  Church  between  1880  and  1882.  He  then  continues: 
"  The  bacteriological  era  in  the  investigation  of  these  forms 
begins  with  Banti,  in  1887-  In  his  case  death  took  place 
on   the   twenty-eighth   day    of   the   disease.      No   intestinal 

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TYPHOID  FEVER  IN  THE  YOUNG 

lesions  were  found,  but  the  spleen  and  mesenteric  glands 
were  swollen ;  in  them  bacilli  morphologically  similar  to 
the  bacillus  typhosus  were  found."  He  quotes  seventeen 
authors,  and  adds  his  own  cases,  without,  however,  men- 
tioning Hodenpyl. 

It  should,  however,  be  stated  that  the  statistics  of  intes- 
tinal ulcerations  with  perforation  are  not  conclusive ;  many 
are  observed  in  private  practice,  not  counted,  not  reported, 
and  forgotten.  Now  and  then,  again,  a  case  is  reported 
as  a  curiosity  without  reference  to  the  number  of  cases 
observed  and  other  important  points.  Barrier  met  with 
two  perforations  in  24  cases,  a  very  unusual  proportion. 

Montmoullin  reports  seven  cases  in  which  perforation  was 
diagnosticated,  three  of  which  recovered^ — a  proportion  of 
spontaneous  recoveries  able  to  arouse  the  jealousy  of  any 
operator. 

Barrier  and  Bouchut  made  long  ago  similar  observations 
on  the  adult,  so  that  they  concluded  that  the  anatomical 
alterations  of  the  intestine  may  be  absent.  Chiari  (Z.  f. 
Heilk.,  1897)  while  finding  lesions  in  the  stomach,  and 
bacilli  in  different  organs,  and  septic  symptoms,  found  no 
intestinal  lesions.  In  nineteen  collected  cases,  while  the 
Widal  test  was  positive,  the  same  absence  of  intestinal 
lesions  was  marked.  So  the  latter  is  not  conclusive.  The 
last  case  of  the  same  nature  was  published  by  A.  Mc. 
Phedran  in  the  October  issue  of  the  Phil.  Monthly  Med. 
Journal  (1899). 

Gurgling  in  the  ileo-cecal  region,  both  with  and  without 
pressure,  is  common  in  intestinal  catarrh,  both  infectious 
and  non-inf ectiovis ;  that  is  why,  under  ordinary  circum- 
stances, it  should  not  be  held  to  be  characteristic  of  typhoid 
fever.  It  would  be  more  so,  if  complicated  with  constipa- 
tion, and  with  some  of  the  more  frequent  symptoms  of 
typhoid  fever. 

Incontinence  of  the  sphincter  ani  when  met  with  is  not 
so  much  the  local  result  of  the  infection  as  of  unconscious- 
ness ;  when  it  occurs  during  convalescence,  it  depends  on 
hyperperistalsis,  mostly  combined  with  colic. 

Tympanites  is  usually  very  moderate,  for  extensive  peri- 
tonitis is  very  uncommon,  except  with  perforation.     Sensi- 

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DR.    JACOBI'S    WORKS 

tiveness  of  the  abdomen  is  frequent,  without  the  diagnosis 
of  local  peritonitis  being  always  within  easy  reach.  This 
latter  form  is,  however,  quite  frequent,  for  in  the  autopsies 
of  children,  or  of  adults  who  died  of  other  diseases,  local 
discolorations  and  thickenings,  of  a  grayish  white,  or  yel- 
low color,  are  often  found  on  the  peritoneal  layer  of  the 
intestine,  above,  near  or  below  the  cecum.  They  are  the 
results  of  previous  local  peritonitis  corresponding  with  the 
locality  of  ulcerations  during  typhoid  fever,  or  any  of  the 
forms  of  enteritis  in  former  years.  Unexpected  perfora- 
tions of  the  intestine,  occurring  in  advanced  years,  during 
apparently  perfect  health,  are  the  final  results  of  such  local 
peritonitis. 

Hemorrhages  in  the  very  young  are  exceptional,  and 
mostly  mild  in  children  of  more  than  four  years.  I  have 
seen  it  more  than  a  dozen  times.  In  a  girl  of  10  years, 
the  loss  of  blood  was  such,  there  being  several  hemorrhages 
in  the  course  of  the  third  week,  that  I  attributed  the  super- 
vening heart  failure  to  exhaustion  only.  Both  the  number 
and  severity  of  the  hemorrhages  appear  to  depend  on  the 
character  of  the  epidemic  or  on  the  season.  In  the  very 
young,  I  sometimes  saw  no  tinge  of  blood  in  five  years, 
and  in  a  single  season  eight  years  ago  I  met  with  two, 
not  fatal,  cases  of  hemorrhage,  in  girls  of  5  and  7  years. 
This  very  autumn  I  have  seen  four  cases  of  typhoid  fever 
in  children  of  from  5  to  9  years,  in  which  mild  hemor- 
rhages occurred.  Of  Henoch's  nine  intestinal  hemorrhages, 
five  were  quite  mild. 

Circulatory  Organs. — The  organs  of  circulation  are  not 
affected  to  the  same  extent  as  in  adults.  The  average 
heart  of  the  young  is  stronger,  and  less  diseased.  Endo- 
and  pericarditis,  embolisms  and  thrombroses  are  rarer  than 
in  advanced  age,  except  in  very  bad  and  protracted  cases, 
in  which  the  myocardium  was  deteriorated  by  the  bacillary 
toxin.  For  the  same  reason  complete  adynamia, is  not  so 
frequent  at  least  in  the  first  week  or  weeks.  During  in- 
creasing inanition,  however,  the  circulation  is  impaired,  as 
best  shown  by  the  coldness  of  the  feet.  The  gums  bleed 
but  rarely,  the  nose  not  so  often  in  infants,  and  the  very 
young,  as  in  older  children.     The  pulse,  mainly  during  the 

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TYPHOID  FEVER  IN  THE  YOUNG 

first  two  weeks,  except  in  the  small  infant,  where  it  is 
liable  to  be  feeble  and  frequent,  is  either  in  correspondence 
with  respiration  and  temperature,  or  frequently  slower  and 
quite  strong.  When  it  becomes  feeble  and  frequent,  with 
or  without  intermissions,  it  impairs  the  prognosis,  and 
demands  persistent  stimulation.     It  is  rarely  dicrotic. 

When  it  is  in  this  weak  condition,  the  heart  sounds  are 
no  longer  distinct;  they  are  muffled,  one  or  the  other  splits 
in  two,  and  an  apex  murmur  becomes  audible.  This 
should  not  be  taken  as  merely  functional;  the  myocardial 
weakness  which  occasions  it  is  toxic  and  organic,  and  may 
remain  a  permanent  lesion. 

Spleen. — The  irregular  respiration  of  nervous,  or  fright- 
ened infants  and  children,  their  tympanitic  colon,  and 
high  diaphragm,  possible  exudation  in  left  pleura  or  lung, 
and  the  struggle  against  examination,  whether  painful  or 
not,  render  the  diagnosis  of  the  condition  of  the  spleen 
difficult.  In  perhaps  one-half  of  the  cases  it  is,  however, 
successful.  Percussion  succeeds  less  than  palpation,  which 
may  reveal  the  lower  edge  of  the  spleen.  It  is  rarely  felt 
before  the  end  of  the  first  week,  about  the  time  when 
roseola  appears ;  earlier,  however,  when  the  fever  is  un- 
usually high.  When  it  diminishes  rapidly  in  the  middle 
of  the  third  week,  the  prognosis  is  good ;  if  not,  there  will 
be  a  relapse.  When  a  relapse  takes  place,  the  spleen, 
which  was  greatly  reduced  in  size,  is  liable  to  swell  very 
rapidly.  Permanence  of  this  swelling  of  the  spleen,  how- 
ever, is  much  rarer  after  typhoid  than  after  severe  ma- 
larial fevers,  and  abscesses  are  quite  exceptional. 

The  Respirator!/  Organs. — The  nasal  mucous  membrane 
is  dry,  covered  with  thin  crusts,  and  irritated  like  the  lips, 
which  are  in  a  similar  condition.  Epistaxis  is  not  infre- 
quent in  older  children.  Together  with  pharyngitis  there 
may  be  a  catarrhal  laryngitis.  This,  and  the  dryness  of 
the  mucous  membrane  cause  hoarseness  and  cough.  Edema 
of  the  glottis,  which  is  fortunately  rare,  causes  dyspnea 
and  strangulation.  Superficial  and  deep  ulceration  of  the 
trachea  or  larynx,  and  perichondritis  are  exceptional,  but 
I  have  met  the  necessity  of  performing  tracheotomy  in 
«uch  cases  twice.     One  was  the  case  of  a  girl  of  seven,  in 

301 


DR.    JACOBI'S    WORKS 

which  scarification  of  the  interior  of  the  larynx  was  un- 
successful— the  child  was  saved  by  the  operation.  Tlie 
other  tracheotomy  was  made  during  convalescence  on  a  boy 
of  ten  years,  because  of  an  abscess  developing  over  and 
behind  the  manubrium  sterni.  He  died  after  many  weeks 
of  pyemia,  the  main  source  of  which  was  found  about  the 
lowest  rings  of  the  trachea,  and  the  mediastinal  lymph- 
nodes.  Bronchial  catarrh  is  frequent,  without  much  cough, 
as  long  as  the  respiration  is  shallow;  with  cough  on  deep 
respiration ;  catarrhal  pneumonia  is  not  rare,  and  mostly 
bilateral;  croupous  pneumonia  is  also  apt  to  be  bilateral. 
The  more  frequent  form  of  pneumonia,  however,  in  the 
protracted  cases  of  feeble  patients,  is  hypostatic,  with  a 
tendency  to  become  bilateral  at  once,  and  to  extend. 
Pulmonary  gangrene  is  exceptional,  but  should  be  feared 
in  every  case  of  infectious  broncho-pneumonia,  compli- 
cated with  a  weak  heart. 

Pleuritis  is  comparatively  rare,  purulent  in  exceptional 
cases  only,  sometimes  sanguinolent,  though  there  be  no 
complication  with  tuberculosis. 

Complications  with  diphtheria  of  the  bacillary  variety 
(nasal,  pharyngeal,  or  laryngeal),  are  not  common.  When 
they  occur  during  the  prevalence  of  a  diphtheria  epidemic, 
they  are  grave  accidents. 

Urinary  Organs. — The  urine  is  mostly  of  a  high  color, 
contains  in  the  beginning  much  urea  and  uric  acid,  less 
chlorides  than  normal,  indican  sometimes,  albumin  fre- 
quently at  an  early  period  and  more  so  during  the  height 
of  the  disease,  renal  epithelia,  blood,  thin  granular  casts, 
and  occasional  bacilli.  The  renal  irritation  exhibited  by 
the  microscopic  appearance  is  that  which  is  usual  in  most 
infectious  diseases,  and  is  due  to  the  effect  of  the  toxin 
while  being  eliminated  through  the  kidneys.  Symptoms  con- 
nected with  this  elimination  need  not  be  very  marked  and 
need  not  lead  to  nephritis.  Still,  the  latter  may  follow. 
Even  pyuria  has  been  found,  for  instance,  by  G.  Blumer, 
in  children,  one  of  13  and  one  of  10  years  (Johns  Hop- 
kins  Rep.,  Vol.  V). 

Retention  of  urine  is  rare  in  children,  but  occurs  when 
there  is  coma  or  much  peritonitis.     In  that  case,  and  when- 

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TYPHOID    FEVER    IN    THE    YOUNG 

ever  it  is  important  to  secure  urine  for  examination,  cathe- 
terizations should  be  resorted  to.  It  is  more  easily  per- 
formed in  the  j^oung  than  in  the  adult  and  more  readily 
in  boys  than  in  girls.  Under  ordinary  circumstances,  when 
the  catheter  is  not  emploj'cd  for  some  reason  or  other  a 
big  ball  of  absorbent  cotton  will  collect  urine  enough  for 
the  usual  examination  of  the  urine.  Polyuria  is  seen  dur- 
ing convalescence  when  much  water  is  drunk.  In  that 
period  dropsical  effusions  may  be  observed  with  or  without 
albumin;  it  should  also  not  be  forgotten  that  salicylic  acid 
or  antipyrin  when  employed  may  cause  edema;  and,  fur- 
ther, that  there  may  be  nephritis  without  albuminuria.  The 
Diazo  test  is  mostly  positive  towards  the  end  of  the  first 
week,  and  remains  so  until  the  middle  of  the  third,  some- 
times very  much  longer.  At  all  events,  however,  its  absence 
is  no  proof  against  the  presence  of  typhoid  fever.  Roem- 
held  missed  it  altogether  in  many  cases. 

The  observations  made  by  Lafleur  and  others,  that  the 
urine  voided  after  cold  bathing  exhibits  a  high  degree  of 
toxicity,  would  rather  speak  in  favor  of  that  treatment; 
for  the  more  toxic  the  urine  and  dangerous  to  the  labora- 
tory animal,  the  less  toxin  there  is  left  in  the  patient. 
Elimination,  as  speedily  as  possible,  is  what  should  be 
aimed  at.  And  whatever  diuretic  effect  there  is  in  cold  bath- 
ing, as  in  other  remedies,  is  welcome  as  long  as  the  con- 
dition of  the  patient  permits  it.  How  rarely  that  is  so, 
will  be  seen  in  the  remarks  I  have  to  make  on  therapeutics. 

Skin. — The  tendency  of  the  skin  is  to  be  dry;  that  is 
why  chronic  eruptions  are  liable  to  disappear  during  the 
illness  and  to  return  when  recovery  is  complete.  This  dry- 
ness is  also  the  cause  of  the  transverse  fissures  under  the 
knee  which  Koebner  explains  by  the  co-operation  of  the 
lifeless  epidermis,  the  vigorous  growth  of  the  extremities 
and  the  flexed  posture  of  the  knee;  it  also  causes  the  ex- 
tensive desquamation  before  and  during  convalescence. 

The  characteristic  roseola  exhibits  the  same  peculiarities 
that  are  noticed  in  the  adult;  it  is  absent  in  perhaps  20  per 
cent.  Morse  collected  671  cases,  in  406  of  which  it  was 
present;  Henoch  found  it  362  times  in  381  cases.  It  is  not 
pncommpjj  iij  the  very  young.     I  found  a  few  spots  on  the 

303 


DR.    JACOBI'S    WORKS 

epigastrium  of  a  newly  born  that  died  on  the  sixteenth  day 
of  its  life;  Gerhardt  (Handb.  Vol.  II,  p.  373)  met  with 
roseola  (and  a  tumefied  spleen)  in  a  baby  of  three  weeks. 
It  may  appear  as  late  as  the  eleventh,  even  the  fifteenth, 
or  seventeenth  day,  is  mostly  not  so  copious  as  it  is  in 
the  adult,  and  occurs  preferably  on  the  chest  and  abdomen, 
but  also  on  the  back  and  on  the  extremities.  When  the 
temperature  is  high  at  an  early  date,  roseola  may  appear 
early,  on  the  third  or  on  the  fourth  day,  and  new  crops  may 
occur  afterwards.  In  relapses  it  is  more  frequently  missed 
than  in  the  primary  attack,  but  a  new  crop  in  the  fourth 
week  means  a  relapse.  Petechiae  are  not  frequent,  but  do 
occur  in  children  of  more  than  seven  or  eight  years,  also  in 
the  very  young;  when  complicated  with  extensive  purpuric 
extravasation  they  are  ominous. 

Miliaria  is  sometimes  observed  when  there  is  exceptional 
perspiration;  and  erythema  during  the  height  of  the  dis- 
ease when  there  is  much  intestinal  disorder  and  coma  as  the 
result  of  direct  toxic,  or  of  auto-infection.  Eczema  is  the 
result  of  uncleanliness  only;  gangrene,  abscesses,  furuncles, 
and  pustules  are  frequent  occurrences,  but  in  the  later 
periods  of  the  disease  only. 

In  bad  cases,  and  mainly  when  the  hygiene  of  the  skin 
was  neglected,  abscesses  will  appear  in  it  and  in  the  sub- 
cutaneous tissue,  preferably  on  the  head,  face  and  chest. 
Slight  irritations  are  sufficient  to  act  as  proximate  causes. 
A  child  of  two  years  developed  the  first  abscess  on  the 
epigastrium  in  consequence  of  a  subcutaneous  injection  of 
quinin.  More  followed,  mainly  on  the  hands,  fingers,  and 
feet,  more  than  sixty  were  incised  in  the  course  of  a  few 
weeks,  until,  finally,  recovery  set  in. 

In  a  child  of  two  years  I  saw  copious  hemorrhages  about 
the  ear,  groins,  and  neck  with  consecutive  gangrene;  in  a 
boy  of  nine,  extensive  destruction  of  the  skin  over  more 
than  one-half  of  the  abdomen;  in  both  cases  with  final  re- 
covery. 

The  desquamation  of  typhoid  fever  may  be  quite  copious 
and  resemble  that  of  measles  or  even  of  scarlatina.  On 
the  other  hand,  some  of  the  eruption  of  the  two  latter  may 
resemble  the  roseola  of  typhoid  fever.     That  is  why  the 

304 


TYPHOID    FEVER    IN    THE    YOUNG 

diagnosis  may  become  difficult,  particularly  as  there  are 
cases  of  which  I  have  seen  some,  in  which  the  latter  and 
one  of  the  former  may  be  contemporaneoMS.  Thus  Cos- 
grave  (Brit.  Med.  Jour.,  Jan.  16,  1897),  reports  five  cases 
in  which  scarlet  and  typhoid  fever  were  coincident  without 
seeming  to  increase  the  degree  of  danger.  Both  started 
at  the  same  time. 

From  George  M.  Gould's  American  Year  Book,  1898,  p. 
625,  I  quote  Amitrano,  who  reports  a  case  of  typhoid  fever 
developing  in  convalescence  a  scarlatiniform  eruption  with 
fever  which  was  followed  by  desquamation.  After  this 
fever  had  subsided  marked  meningeal  symptoms  appeared 
for  a  few  days.  These  disappeared,  and  after  desquamation 
was  complete  a  second  intense  erythema  appeared,  which 
was  also  followed  by  desquamation,  after  which  recovery 
ensued. 

Bones. — The  bones  suffer  in  different  ways.  The  charac- 
teristic increase  of  growth  after  infectious  fevers  is  mostly 
observed  in  scarlet,  and  in  typhoid  fevers.  Epiphyseal  and 
general  pain  about  the  extremities  is  frequent  in  typhoid 
fever,  and  some  degree  of  epiphysitis  is  common,  in  conse- 
quence of  this  irritation.  Periostitis  and  osteomyelitis  have 
been  observed,  and  bacilli  have  been  found  in  the  latter. 
Before  the  advent  of  the  bacillus,  I  lost  a  child  of  four 
years  with  osteomyelitis  of  the  right  femur,  in  spite  of 
early  operation.  Such  cases  are  fortunately  not  frequent, 
but  it  appears  they  occur  in  from  one  to  two  per  cent, 
of  all  typhoid  fevers.  Chondritis  is  still  more  infrequent, 
with  less  serious  results. 

Nervous  System. — The  nervous  system  of  the  young  is 
believed  not  to  be  affected  by  typhoid  fever,  as  it  is  in  the 
adult.  There  are  cases  in  which  the  general  condition  of 
the  patient  appears  to  be  unusually  good,  compared  with 
the  toxic  nature  of  the  whole  process,  and  with  the  height 
of  the  temperature.  In  many  instances  I  concluded,  from 
nothing  but  the  apparent  comfort  and  ease  of  the  patient, 
when  the  high  temperature  would  have  suggested  the  pres- 
ence of  severe  subjective  symptoms,  that  everything  but 
typhoid  fever  could  be  excluded.  The  same  holds  good  of 
that  in  adults.     In  them  ambulant  cases  are  by  no  means 

305 


DR.    JACOBI'S    WORKS 

rare,  and  those  in  bed  often  demand  permission  to  get  up, 
expressing  the  most  complete  satisfaction  with  their  con- 
dition, while  their  temperature  ranges  at  or  above  104. 
Other  children  are  apathetic,  or  somnolent,  or  peevish,  and 
restless.  The  "  typhoid  state "  should  not  by  itself  be 
taken  as  a  symptom  of  typhoid  fever.  It  may  be  absent 
altogether,  and  is  found  now  and  then  when  there  is  no 
typhoid.  Headache  is  frequently  complained  of,  or  is  be- 
trayed by  vertical  wrinkling.  Hearing  may  be  bad,  the 
conjunctiva  injected  and  the  cornea  cloudy  under  the  in- 
fluence of  the  toxic  disturbance  of  the  trifacial  nerve. 
Grinding  of  the  teeth,  sopor,  or  delirium,  and  vehement 
screams  resembling  those  of  meningitis,  are  occasionally 
met  with.  Such  symptoms,  though  ever  so  severe,  need 
not  correspond  with  the  elevation  of  the  temperature  at 
all;  the  latter  may  be  rather  low,  while  the  intoxication 
is  quite  pronounced.  Not  every  case  of  seeming  cerebral  or 
meningeal  symptoms  should  be  attributed  to  cerebral  af- 
fection only;  still,  contractures,  or  convulsive  movements 
may  occur  when  there  is  an  effusion  from  the  pia  mater. 
Such  complications  of  genuine  meningitis  with  typhoid 
fever  certainly  occur,  and  not  only  after  the  eighth  or 
tenth  year  when  gradually  the  typhoid  fever  in  the  young 
resembles  more  and  more  that  of  advanced  age.  Kernig's 
symptoms  may  be  employed  to  clear  up  the  diagnosis  of 
genuine  meningitis. 

Some  of  the  symptoms  common  to  both  may  be  explained 
differently.  Vomiting  may  be  due  to  the  toxic  degeneration 
of  the  cerebral  substance,  or  to  meningitis,  or  to  the  ab- 
normal condition  of  the  stomach,  or  even  of  the  pharynx,  or 
to  nephritis.  Coma  or  delirium  I  have  seen  in  typhoid,  in 
meningitis,  also  in  cinchonism,  and  under  the  influence  of 
salicylic  acid. 

As  a  consecutive  symptom  aphasia  was  found  twenty 
times  by  Henoch;  half  a  dozen  times  I  have  seen  it  in  the 
course  of  many  years ;  with  the  exception  of  one  that  sud- 
denly died,  probably  of  mj'ocardial  degeneration,  all  of 
them  got  well.  Polyneuritis  is  not  rare.  In  severe  epi- 
demics it  is  frequently  seen,  usually  with  a  favorable  ter- 
pjination.      It  is  due   to   tissue   alterations,   occasioned  by 


TYPHOID    FEVER    IN    THE    YOUNG 

the  influence  of  the  bacillary  toxin.  Hemiplegia  is  rarely 
observed;  a  case  of  "  cerebellar  ataxia  "  in  a  boy  of  suven, 
which  terminated  in  recovery,  was  reported  by  Luigi  Con- 
cetti, in  La  Pediatria,  No.  8,  1898. 

Paraplegia  is  more  frequent,  and  still  more  so  is  local 
paralysis,  under  the  influence  either  of  the  toxin,  or  of  a 
hemorrhage,  or  of  an  embolus.  Amongst  them  are  paraly- 
sis of  the  glottis,  which  necessitated  a  tracheotomy  in  a  case 
of  Rehn's,  and  of  the  abducens  (which  I  have  seen  in 
quite  a  number  of  cases,  most  of  which  were  obstinate, 
some  permanent)  and  of  the  accommodation  muscles  of  the 
eye.  Paralysis  of  the  sphincter  of  the  bladder  is  not  in- 
frequent. 

Psychical  disturbances  are  seen  as  the  sequelae  of  every 
infectious  fever,  mainly  scarlatina  and  typhoid.  Four  such 
cases  were  reported  by  S.  S.  Adams  to  the  American  Pedi- 
atric Society  in  1896.  They  may  result  from  inanition, 
or  from  the  parenchymatous  tissue  changes  caused  by  the 
toxin,  or  from  meningitis.  Mania  and  melancholia  are 
the  two  forms  mostly  met  with.  Not  all  of  them  termin- 
ate favorably.  Two  of  my  early  cases  died  in  lunatic 
asylums  in  rather  advanced  years.  The  motor  disturbances 
not  paralytic,  which  follow  typhoid,  particularly  chorea, 
have  all  got  well  in  my  recollection,  a  few  only  with  re- 
lapses. It  struck  me  that  post-typhoid  chorea  was  less 
subject  to  recurrences  than  other  forms. 

I  now  give  the  particulars  of  two  sets  of  observations, 
which  will  prove  that  the  symptoms,  course  and  complica- 
tions of  the  typhoid  fever  of  the  young  may  greatly  diff"er 
from  one  another,  or  from  any  average  description  of  its 
nosology.     One  I  published  in  the  Arch  Ped.,  March,  1885. 

The  number  of  typhoid  fever  cases  treated  in  the  Chil- 
dren's Pavilion  of  Bellevue  Hospital,  from  October,  1882, 
to  September,  1884,  was  25.  Of  these  11  were  males,  14 
females;  17  ran  a  single  course,  5  had  relapses,  3  were 
sick  over  a  period  of  from  four  to  six  weeks,  without  per- 
mitting the  second  attack  to  be  distinguished  from  the 
first  by  an  alleviation  of  the  symptoms.  In  seven  cases 
a  distinct  chill  was  mentioned  as  ushering  in  the  illness; 
in   half   a   dozen   more   several   attacks   of   chilliness   were 

307 


DR.    JACOBI'S    WORKS 

noticed.  The  ages  of  the  patients  ranged  from  2  to  14 
years,  the  average  9-  Pain  in  the  ileo-cecal  region  was 
complained  of  in  fourteen  cases,  diarrhea  was  noticed  in 
fifteen,  bloody  stools  not  amounting  to  hemorrhages  in 
three;  in  three  constipation  was  mentioned  as  a  notable 
fact ;  in  the  first  week  of  six  epistaxis  was  observed.  Tume- 
faction of  the  spleen  was  noted  in  sixteen ;  roseola  was 
observed  in  fourteen  cases.  Its  first  appearance  was  no- 
ticed between  the  fifth  and  seventh  day;  it  lasted  from 
five  to  ten  days.  Premonitory  symptoms  were  reported  in 
nine  cases ;  in  four  they  lasted  two  weeks.  They  consisted 
in  lassitude,  loss  of  appetite,  change  of  temper,  and  in 
some  few  cases,  diarrhea  set  in  a  week  before  the  initiating 
chill  or  chilliness.  Five  of  my  cases  died ;  one  remained 
stupid  and  hard  of  hearing  for  sometime,  but  recovered. 

Contrary  to  my  experience,  as  expressed  in  a  lecture  on 
typhoid  fever  (Medical  Record,  Nos.  17  and  18,  1879), 
in  which  I  claimed  a  mild  type  and  a  low  mortality  for 
the  typhoid  fever  of  infancy  and  early  childhood,  this 
Bellevue  service  of  mine  had  a  mortality  of  20  per  cent. 
— similar  to  that  of  CEsterlen,  who  estimated  it  at  22  per 
cent.,  and  Friedrich,  who  reported  23  per  cent.,  in  chil- 
dren under  five  years  of  age. 

In  1882  and  1883  we  had  a  bad  epidemic  of  typhoid 
amongst  all  classes  and  ages.  The  guests  of  summer  hotels 
and  boarding  houses  imported  hundreds  of  cases,  and  the 
whole  population  suffered  in  consequence,  infants  and  half- 
grown  children  as  much  as  the  rest,  and  the  mortality  all 
over  the  city  was  high.  The  hospitals  have  always  more 
than  their  share,  however,  and  their  statistics  must  neces- 
sarily be  erroneous.  Errors  are  occasioned  by  the  fact 
that  with  us  at  least  hospitals  do  not  contain  the  average 
cases,  but  as  a  rule  those  only  who  fare  badly  and  promise 
badly.  A  poor  family  will  nurse  their  children,  while  they 
require  but  little  care;  only  that  one  which  is  seriously 
ill,  and  gives  a  great  deal  of  trouble  and  a  bad  prognosis, 
is  sent  to  the  hospital.  Of  that  class,  many  will  die. 
That  is  why  the  mortality  of  a  hospital  does  not  indicate 
the  general  character  of  the  epidemic.  That  is  also  why 
the  general  practitioner,  singly  or  collectively,  is  the  better 

308 


TYPHOID    FEVER    IN    THE    YOUNG 

judge  and  statistician.  He  sees  all  the  cases  in  a  family, 
those  remaining  at  home,  and  those  sent  to  a  hospital; 
sees  the  mild  and  the  severe  cases,  and  counts  those  who 
survive.  Six  cases  in  a  family,  one  of  which  is  sent  to 
and  dies  in  the  hospital,  may  give  the  family  practitioner 
a  mortality  of  l6,  the  hospital  attendant  one  of  100  per 
cent. 

Another  series  of  observations  was  published  by  F. 
Sbrana  (Arch,  de  Med  des  Enf.,  Jan,  1899).  He  reports 
on  seventy-two  cases  of  typhoid  children,  from  16  months 
to  8  years  old,  whom  he  observed  in  Tunis;  75  per  cent, 
of  all  cases  occurring  in  that  sub-tropical  city  were  in 
children ;  in  one  family  there  were  four,  in  another  three 
cases.  Why  there  should  be  a  prevalence  of  cases  in 
children,  is  perhaps  best  explained  by  Jeannel's  report 
made  to  the  Fourth  French  Congress  of  International  Medi- 
cine, in  1898.  He  observed  an  epidemic  of  typhoid  fever, 
in  which  the  communication  may  have  occurred  through 
the  dust  of  the  street  into  which  the  typhoid  dejections 
were  thrown.  The  principal  and  first  sufferers  were  chil- 
dren who  were  playing  in  the  street,  and  not  very  particu- 
lar as  to  what  they  carried  to  their  mouths.  Both  their 
size  and  their  habits  I  counted  many  years  ago  and  re- 
peatedly since,  amongst  the  causes  of  the  frequency  with 
which  follicular  angina,  and  also  diphtheria  are  observed 
amongst  the  young. 

The  premonitory  symptoms  of  the  majority  of  cases  con- 
sisted in  anorexia,  with  headache,  vomiting  and  constipa- 
tion; the  run  of  temperatures  was  quite  irregular.  In  50 
per  cent,  there  was  epistaxis  in  the  beginning;  diarrhea 
began  at  a  later  period  of  the  disease.  Gurgling  in  the 
ileo-cecal  region  was  not  observed  in  patients  less  than 
three  years  old,  and  was  altogether  not  common.  Roseola 
was  noticed  in  one-third  of  the  cases,  the  spleen  was  en- 
larged in  every  one  after  the  fifth  or  sixth  day.  There 
was  no  intestinal  hemorrhage,  and  the  fever  disappeared 
by  lysis.  There  was  a  furfuraceous  desquamation  in  four 
cases ;  the  mortality  was  1 1  per  cent. 

There  were  many  complications;  suppurating  parotitis  in 
two;  peritonitis  from  perforation,  one;  purulent  pleuritis, 

309 


DR.    JACOBI'S    WORKS 

one,  with  considerable  dilatation  of  the  stomach  during 
convalescence;  aphasia  in  five;  orchitis  of  the  left  side 
without  suppuration,  one;  and  meningitis,  three;  two  of 
the  last  terminated  fatall3^  All  these  cases  looked  very 
much  like  cerebro-spinal  meningitis ;  still  there  was  the 
tumefied  spleen,  and  no  herpes.  In  other  cases  there  were 
milder  cerebral  symptoms,  such  as  dysphagia,  partial  con- 
vulsions, aphasia,  and  inequality  of  the  pupils,  without 
strabismus,  or  vomiting. 

AGE,     MORTALITY 

Friedleben  placed  the  greatest  frequency  of  typhoid  in 
childhood  between  the  5th  and  8th  year,  Griesinger  be- 
tween the  5th  and  11th,  Loeschner  and  Friedrich  between 
the  5th  and  9th,  Rilliet  and  Barthez  between  the  9th  and 
14th,  Barrier  between  the  5th  and  15th  year,  and  Faucon- 
net  between  the  10th  and  20th  year.  A  few  other  figures 
contained  with  the  above  in  Gerhardt's  Handbuch,  Vol.  II., 
are  as  follows:  Murchison  noticed  that  20  per  cent,  of  all 
the  inmates  of  the  fever  hospital  were  less  than  15  years. 
Von  Franque  collected  all  the  typhoid  cases  of  the  province 
of  Nassau,  and  found  2021  of  11,028  to  be  less  than  10 
years,  Gaultier  gathered  many  French  statistics,  and  re- 
ported 31  per  cent,  below  15  years.  In  a  small  town 
Baginsky  counted  sixteen  cases  under  10  years  out  of  a 
total  of  50,  Rosenthal  28  in  115,  Schaedler'll  in  144. 

Holt  (Textbook,  p.  1008)  quotes  970  cases  from  eight 
authors;  8  per  cent,  were  under  5,  42  per  cent,  from  5 
to  10,  50  from  10  to  15  years  old.  Montmoullin  (These  de 
Paris,  1885)  reported  fifteen  cases  under  two  out  of  a  total 
of  295  under  15  years.  Schavoir,  in  Stamford,  Conn., 
collected  406  cases  of  all  periods  of  life;  of  these  68 
were  under  5  years,  72  between  5  and  10  years.  Morse 
reports  284  cases  in  the  Boston  City  Hospital ;  3  were 
under  5  years,  77  from  the  fifth  to  tenth,  and  204  from 
the  tenth  to  the  fifteenth  year.  He  also  concluded  that 
typhoid  is  unusual  in  infancy,  because  the  Widal  reaction 
was  negative  in  two  cases  of  simple  diarrhea,  forty-five 
cases  of  fermental  diarrhea,  and  three  of  ileo-colitis,  with 
the  exception  of  one  whose  mother  had  typhoid  fever  years 
before.     It  will  be  seen,  however,  that  in  none  of  these 

310 


TYPHOID    FEVER    IN    THE    YOUNG 

cases  the  diagnosis  of  typhoid  fever  was  made  or  suggested. 
As  there  was  no  typhoid  there  was  no  Widal. 

All  these  figures  and  results  are  in  confirmation  of  the 
earliest  observations.  Griesinger,  for  instance,  wrote  in 
1857  (Virch.  Handh.,  II.,  2,  124):  "Typhoid  fever  is 
very  rare  in  the  earliest  infancy;  it  is  only  from  the  sec- 
ond to  the  third  year  that  the  disposition  becomes  greater; 
after  that  time  it  grows  rapidly,  so  that  typhoid  fever  is 
quite  frequent  amongst  us."  (Germany.)  Bouchut  denies 
the  occurrence  of  typhoid  in  the  newborn.  According 
to  him   it  occurs   first  between   the  first  and  second  year. 

There  are,  however,  well  observed  cases  of  typhoid  fever 
in  the  newborn.  Gerhardt  quotes  Charcellay  who  saw 
it  in  a  child  of  eight  days;  Bednar,  five  days;  Necker, 
thirteen  days,  and  reports  a  case  of  his  own  at  three 
weeks.  I  had  a  case,  the  mother  having  typhoid  fever  when 
the  child  was  born.  In  the  latter  I  diagnosticated  the 
disease  on  the  ninth  day.  There  were  a  few  spots  on  the 
epigastrium  on  the  sixteenth  day,  a  large  and  soft  spleen, 
and  Peyer's  plaques  swollen  and  rather  soft,  not  yet  ul- 
cerated. The  infant  died  on  the  sixteenth  day  of  her 
life.  C.  P.  McNabe  {New  York  Medical  Journal,  Feb. 
19th,  1898),  observed  typhoid  fever,  complicated  with 
whooping  cough  and  pneumonia  in  a  baby  a  few  weeks 
old. 

The  possibility  of  the  transmission  of  typhoid  fever  to 
the  fetus  is  beyond  any  doubt.  Clinical  experience  proves 
such  a  transmission  for  typhoid  fever,  malaria,  measles, 
scarlatina,  variola  and  syphilis;  also  in  erysipelas,  relaps- 
ing fever,  tuberculosis  and  sepsis.  In  young  sheep  anthrax 
was  found  as  early  as  1882;  chicken  cholera  and  glanders 
are  transmitted  in  the  same  way.  But  it  is  possible  that 
the  epithelium  of  the  placenta  is  a  frequent  barrier,  and 
the  suggestion  of  Malvoz's  that  the  transmission  of  an 
infectious  disease  from  the  mother  to  the  fetus  takes  place 
only  when  the  villous  epithelium  is  injured,  I  have  always 
considered  to  be  correct.  He  emphasizes  the  fact  that  of 
twins  one  vaaj  be  affected  while  the  other  goes  free.  All 
these  points  are  discussed  by  W.  Fordyce  in  the  Brit.  M. 
Jour.,  of  Feb.  19th,  1898.'  The  typhoid  fever  of  the 
mother   may   destroy  the   fetus,   may   allow   it   to  be  born 

311 


DR.    JACOBI'S    WORKS 

alive  but  weak,  or  alive  and  vigorous.  Which  of  these 
results  occurs  depends  on  the  amount  of  bacillary  toxin 
transmitted  or  on  circumstances  unknown  to  us  in  an  in- 
dividual case.  But  the  facts  are  firmly  established.  The 
fetal  intestine  was  found  diseased  by  Manzoni  in  1811, 
Charcellay  in  the  same  j^ear,  W^eiss  in  1862.  Bacilli  were 
found  in  the  fetus  by  Reher  and  Neuhaus  in  1886;  in 
the  blood  by  Eberth  in  1893;  and  the  same  results  were 
obtained  by  Freund,  Levy,  Ernst,  and  Durck.  Other  good 
observations  were  made  on  the  living  child.  The  Widal 
test  was  found  positive  in  a  healthy  infant  7  weeks  old, 
that  was  born  when  the  mother  was  in  the  third  week  of 
typhoid  fever,  by  Crozier  Griffith  (Med.  News,  May  15th, 
1*897);  and  by  Mosse  (Progres  Med.,  March  13,  1897)  in 
a  newly  born,  whose  mother  had  typhoid  fever  when  in 
the  sixth  month  of  her  pregnancy,  and  whose  milk  and 
placental  blood  gave  the  same  positive  reaction.  Perhaps 
the  case  of  Landouzy's  will  also  prove  the  possibility  of 
transmission  though  not  through  the  placenta  (Soc.  de 
Biol.  Nov.  6,  1897).  A  healthy  baby  showed  a  positive 
Widal  test,  while  the  woman  had  typhoid  three  months 
after  confinement.  As  the  baby  had  no  other  symptoms  of 
typhoid  fever,  it  is  fair  to  suggest  or  to  believe  that  trans- 
mission to  a  sufficient  degree  took  place  through  her  milk. 

The  transmission  of  typhoid  bacilli  into  the  fetus  is  dem- 
onstrated by  a  case  reported  by  Etienne  (Gaz.  hehdom., 
1896,  No.  16).  A  woman  of  18  years  expelled  on  the 
twenty-ninth  day  of  her  typhoid  fever  a  fetus  in  the 
fifth  month  of  uterogestation.  In  its  blood  taken  from  the 
right  heart,  the  spleen,  the  liver  and  the  placenta  were 
typhoid  bacilli,  but  no  changes  in  the  other  organs.  It  ap- 
pears that  the  death  of  the  fetus  resulted  from  the  toxin 
which  acted  so  rapidly  that  the  organs  had  no  time  to 
participate  in  the  process. 

If,  however,  typhoid  fever  has  been  found  by  some  in  the 
fetus,  in  the  newborn,  in  the  nursling,  there  are  those 
who  never  saw  it  at  that  age,  and  therefore  are  inclined 
to  deny  its  occurrence. 

In  the  Arch.  Ped.,  1895,  p.  91 6,  Dr.  W.  P  Northrup 
speaks  of  the  results  of  2,000  autopsies  in  children  under 

312 


TYPHOID    FEVER    IX    THE    YOUNG 

5  3'ears.  Not  one  presented  the  lesions  of  typhoid  fever. 
He  also  quotes  Dr.  N.  Page  of  tlie  Children's  Hospital  in 
Philadelphia,  who  says:  "  I  have  had  from  six  to  ten  ty- 
phoid cases  in  children  in  the  house  constantly  since  I  came 
on  duty  here,  but  not  one  of  them  was  under  6  years." 
Dr.  Ch.  G.  Kerley  observed  not  a  single  case  of  typhoid 
fever  among  1,326  children,  85  per  cent,  of  whom  were 
under  2  years,  and  9^  p^^r  cent,  under  5  years  of  age ;  nor 
was  a  single  typhoid  lesion  found  in  410  autopsies.  He 
adds  that  there  was  no  case  in  the  three  years  following 
his  observations,  under  his  successor  in  office. 

Again,  however,  Steil'en  reports  on  148  cases  of  typhoid 
in  the  young;  2  were  less  than  1  year,  26  from  the  third 
to  the  sixth,  34  between  6  and  9  years.  Of  Wolberg's 
277  cases,  however,  the  majority  were  as  usual  from  6  to 
12  years  old.  Henoch  reports  on  9  cases  below  2  years, 
59  from  3  to  5,  and  187  from  5  to  10  years,  with  a  mor- 
tality of  12  per  cent.  He  also  reports  of  the  finding  of 
typhoid  ulcerations  14  times  in  26  autopsies.  Ashby  and 
Wright  declare  typhoid  fever  to  be  "  not  common  under  3 
years,"  while  Rilliet  and  Taupin  as  early  as  1840  pro- 
nounced it  to  be  "  not  at  all  rare."  About  the  same  time 
Billard  published  his  experience.  According  to  him  ty- 
phoid fever  was  rare  in  the  first  year,  increased  slowly 
toward  the  fifth,  and  was  quite  frequent  between  the  fifth 
and  fifteenth. 

Maria  Rivoire  described  an  epidemic  which  reigned  in 
Marseilles  in  1896  and  1897  {These  de  MontpelUer,  1898). 
In  and  after  May  of  1897  there  were  105  cases  among 
children,  of  whom  21  died — 20  per  cent.;  in  1896  43  cases 
with  15  deaths — 31  per  cent.  Of  1270  cases  collected 
during  those  two  years  there  were: 

Below  5   years  26,  6  deaths — 23  per  cent. 

Between     5  and  10  years     59,  13  deaths — 22      per  cent. 


15  " 

20  " 

■   289,  42 

"  —14.5 

20  " 

25   " 

■   347,  63 

"  —18.5 

25  " 

30   " 

'   262,  54 

"  —20.5 

30  " 

40   ' 

'   154,  25 

'  —17 

40  " 

50  " 

30,  7 

"  —23 

Above  5  years 

10,  no 

deaths. 

' 

313 

DR.    JACOBI'S    WORKS 

According  to  these  figures  the  largest  mortality  occurred 
between  the  tenth  and  fifteenth  year;  the  mortality  of 
children  below  5  or  below  10  years  equalled  that  of  adults 
between  the  fortieth  and  fiftieth  year. 

H.  Curschmann  (Nothnagel,  Spec,  Pathol,  u.  Therap. 
III.)  reports  on  451  children  (250  male  and  201  female) 
observed  with  typhoid  fever  in  the  Hamburg  Hospital  be- 
tween 1886  and  1887.  Of  these,  seven  were  2;  nine  were 
3 ;  sixteen,  4 ;  eighteen,  5 ;  thirteen,  6 ;  twenty-two,  7 ; 
twenty-seven,  8;  forty-four,  9;  fifty,  10;  fifty,  11;  sixty, 
12;  seventy-one,  13;  and  sixty-four  14  years  old. 

Of  Brouardel's  16,036  cases  observed  between  1880  and 
1889^  36  were  1  year  and  under,  1,041  under  5,  1,265 
from  6  to  10,  and  1,386  from  11  to  15  years  old. 

According  to  an  excellent  report  published  by  Dr.  I. 
Rudisch,  in  the  Mount  Sinai  Hospital  reports  (1899)^  on 
974  cases  of  typhoid  fever,  which  occurred  from  1883  to 
1898,  124  occurred  in  children  below  ten  years,  and  90 
between  the  eleventh  and  fifteenth;  a  total  of  214  cases. 
Of  these  one  was  six,  another  ten  months  of  age.  There 
were  altogether  below  five  years  37  cases,  six  of  which 
died  =  16.21  per  cent.,  and  87  between  the  sixth  and  tenth, 
7  of  which  died  :^  8.75  per  cent.  The  exact  figures  for 
the  first  year  were  5  cases  with  3  deaths,  for  the  second 
6  with  no  death,  the  third  5  with  no  death,  the  fourth  10 
with  1  death,  the  fifth  11  with  2  deaths,  the  sixth  l6  with 
2,  the  seventh  20  with  1,  the  eighth  11  with  no  death,  the 
ninth  24  with  3,  the  tenth  16  with  1,  and  from  the  eleventh 
to  the  fifteenth  90  cases  with  9  deaths. 

One  of  the  principal  points  made  by  Dr.  Northrup  is 
that  the  ulcerations  claimed  for  typhoid  fever  are  not 
characteristic  at  all;  that,  indeed,  they  are  found  in  com- 
mon intestinal  diseases  of  non-infectious  nature.  That  is 
what  Hervieux  contended  thirty  years  ago,  when  he  said 
that  follicular  swellings  and  superficial  ulcerations  in  the 
intestines,  and  swelling  of  the  mesenteric  lymph  nodes 
were  found  without  any  specificity  in  the  morbid  process. 

This  observation,  and  the  assumption  of  uniformity  in 
the  nature  of  these  ulcerations,  was  indeed  the  reason  why 
in   France   for  a  long  time   the   terms   typhoid   fever   and 

314 


TYPHOID    FEVER    IN    THE    YOUNG 

dothienenterite  were  synonymous.  But  as  early  as  1877 
C.  Gerhardt  emphasized  the  fact  that  the  peculiar  typhoid 
("  markige ")  infiltration  and  the  formation  of  scurfs, 
which  are  mentioned  now  and  then  are  distinctively  different 
from  the  ulcerations  of  follicular  or  other  enteritis.  It  is 
true,  however,  that  in  many  cases  there  is  a  difference  be- 
tween the  young  and  the  adult.  The  changes  in  the  plaques 
of  the  former  are  more  hyperplastic  (they  are  not  so  in 
enteritis),  of  the  adult  more  necrobiotic.  Nowadays  the 
presence  of  the  bacillus  typhosus  in  and  about  doubtful 
ulcerations  would  furnish  another  positive  diagnostic  sign. 

DIAGNpSIS 

It  is  determined  by  the  symptoms  enumerated  above, 
and  while  it  is  mostly  easy  in  the  adult,  becomes  more 
difficult  in  the  very  young.  I  choose  to  take  it  for  granted 
that  in  doubtful  cases  the  diagnosis  of  dentition  and  worms 
is  nowadays  confined  to  a  certain  class  of  illiterate  women 
and  obsequious  practitioners  only;  but  the  differential  diag- 
nosis of  the  typhoid  in  the  very  young  from  a  catarrhal 
fever,  or  influenza,  or  glandular  fever,  even  from  an  in- 
testinal auto-infection  may  remain  difficult  through  many 
days^ — even  for  the  skilled  and  thinking.  The  fever  curve 
is  very  apt  to  be  irregular,  mainly  in  enfeebled  children 
and  in  the  presence  of  one  of  the  many  complications. 
There  are  even  some  cases  in  which  the  disease  sets  in 
suddenly  with  a  high  temperature;  there  are  those,  how- 
ever, in  which  a  high  temperature  is  apt  to  be  deceptive, 
for  I  believe  with  A.  Fairbarn  {Jour.  Am.  Med.  Ass.,  April 
12,  1897)  that  the  first  symptoms  may  be  overlooked  for 
many  a  day.  A  cerebral  pneumonia  may  exist  half  a  week 
or  more  without  being  recognized,  until  the  development  of 
the  disease  and  careful  examination  clears  up  the  diagnosis. 
Influenza  may  assume  the  characteristics  of  typhoid  to  a 
certain  extent.  Meningitis  may  be  recognized,  if  by  no 
other  symptoms,  by  means  of  a  lumbar  puncture  and  ex- 
amination of  the  cerebro-spinal  fluid.  Altogether  a  rather 
slow  pulse  when  not  in  proportion  to  the  height  of  the 
temperature,  the  condition  of  the  tongue,  the  swelling  of 

S15 


DR.    JACOBI'S    WORKS 

the  spleen,  and  the  presence  of  roseola  render  the  diagnosis 
secure  even  without  the  Diazo  and  Widal  tests.  In  other 
instances,  however,  we  arrive  at  a  result  by  exclusion  only. 
There  is  hardly  a  single  clinical  symptom  which  alone 
proves  the  presence  of  typhoid  fever;  the  simultaneous 
presence  of  many  is  a  more  perfect  guide.  The  diazo  test 
is  nearly  conclusive  when  tuberculosis  and  pneumonia  may 
be  excluded;  it  may  be  expected  to  be  positive  in  90  per 
cent,  of  all  the  cases  between  the  end  of  the  first  and  the 
middle  of  the  third  week.  The  greatest  difficulty  is  met 
with  in  those  infants  that  yield  few  or  no  local  symptoms 
except  those  of  a  septic  infection  only.  Lymph  nodes  are 
sometimes  found  tumefied;  their  swelling  in  the  inguinal 
region,  however,  from  other  causes  is  so  frequent  that, 
when  found  alone  it  should  not  count.  The  presence  of 
herpes  should  generally  be  taken  as  proof  of  the  absence 
of  typhoid  fever.  The  presence  of  the  bacillus  in  the 
discharges  would  be  the  best  symptom  if  we  commanded  a 
readier  practical  method  for  its  discovery,  provided  there 
be  other  symptoms  which  make  the  case  suspicious  of  be- 
ing typhoid  fever.  , 

Much  is  naturally  made  of  the  presence  of  bacilli  in  the 
discharges  of  doubtful  cases,  and  quite  often  the  diagnosis 
had  to  depend  on  it.  To  what  extent  is  that  justified.'' 
There  may  be  cases  in  which  I  should  utterly  refuse  to  ac- 
cept the  diagnosis  of  typhoid  fever  unless  there  be  some 
one  or  more  adjuvant  symptoms,  for  the  same  reason  that 
makes  me  refuse  the  diagnosis  of  diphtheria  when  there 
is  nbthing  but  the  presence  of  Klebs-Loeffler  bacilli,  or 
that  of  tuberculosis  when  bacilli  are  deposited  on  some 
mucous  membrane. 

PROGNOSIS 

The  character  and  the  mortality  of  typhoid  fever  are 
apt  to  vary  according  to  seasons  and  epidemics.  Bagin- 
sky  places  the  mortality  at  9  per  cent.,  Montmoullin  at 
8.8,  Steffen  at  6.7,  Henoch  at  7.5,  Wollberg  at  4.7.  In  hos- 
pitals it  is  liable  to  be  greater  than  in  general  practice 
for  the  reason  that  as  a  rule  bad  cases  only  are  sent  to 
public   institutions.     Still,  in  the    Children's   Hospital   of 

S16 


TYPHOID    FEVER    IN    THE    YOUNG 

Philadelphia  there  were  137  cases,  three  of  whom  died 
(2.66  per  cent.)  ;  in  the  Boston  City  Hospital,  the  mor- 
tality in  284  children,  under  15  years,  was  6  per  cent., 
while  amongst  3,396  adults  it  was  13.5  per  cent.,  and  Holt 
collects  2,623  children  with  a  mortality  of  5.4  per  cent. 
On  the  other  hand,  of  Schavoir's  (New  York  Medical 
Record,  1895)  192  patients  (mostly  in  private  practice), 
under  15  years,  2  died  ^  1  per  cent. 

Nurslings  and  the  very  young,  also  those  approaching 
adolescence,  are  more  endangered  than  those  in  the  inter- 
mediate years,  according  to  Roca  (Ann.  de  Policlin.  de 
Bordeaux,  1897),  and  Roemheld  (Jahrb.  f.  Kinderh,,  Vol. 
48).  High  continuous  temperatures  are  not  always  fatal, 
though  they  be  complicated  with  a  frequent  pulse,  nor  are 
petechiae  absolutely  ominous.  A  moderately  slow  pulse, 
and  the  occurence  of  marked  remissions  are  favorable,  par- 
ticularly when  the  fever  is  not  terminated  within  three 
weeks.  This  continuation  beyond  the  usual  time  is  quite 
common  in  the  very  young,  and  when  the  case  is  ap- 
parently mild.  A  speedy  recovery  may  be  expected  when 
the  spleen  gets  smaller  about  the  sixteenth  or  seventeenth 
day;  if  it  remains  large,  the  case  will  go  on.  Compli- 
cations of  any  kind,  pneumonia,  meningitis,  previous  heart 
diseases,  with  feeble  peripheral  circulation  (cold  feet), 
laryngeal  edema,  hepatic  or  splenic  abscesses  add  to  the 
danger;  that  with  malaria  is  not  very  dangerous  provided 
it  be  recognized  at  an  early  time.  Some  of  these  compli- 
cations are  frequently  called  sequelae;  but  as  they  share 
in  the  microbic  etiology  of  the  disease,  they  should  be  con- 
sidered here.  To  this  class  belong  erysipelas  (mostly 
facial),  otitis  media,  hematomata,  which  are  sometimes  very 
large  and  destructive  to  the  implicated  or  superjacent  cutis, 
arthritis,  furunculosis,  abscesses  of  all  kinds,  and  occasion- 
ally an  anemic  dropsy,  not  attended  with  an  affection  of 
the  kidney,  the  occurrence  of  which  was  noted  by  Grie- 
singer  nearly  half  a  century  ago. 

Relapses  are  by  no  means  rare,  either  after  complete 
apyrexia,  or  with  a  moderate  amount  of  remission  about 
the  end  of  the  third  week,  or  without  any  or  much  change 
in  the  temperature.     They  come  after  apparently  mild,  or 

317 


DR.    JACOBI'S    WORKS 

after  severe  cases,  without  or  with  errors  in  hygiene  or 
diet;  when  there  was  apyrexia,  they  were  mostly  of  a 
shorter  duration  than  when  the  fever  remain  continuous,  or 
exhibited   a   slight   remission   only. 

TREATMENT 

The  food  should  be  liquid.  My  invariable  rule  is,  with 
adults  also,  to  insist  upon  that  demand  until  apyrexia  has 
lasted  ten  days.  The  patient  should  be  encouraged  to  drink 
water  frequently;  the  admixture  of  from  eight  to  twelve 
drops  of  dilute  hydrochloric  acid  to  a  tumbler  full  of  water, 
or  sweetened  water,  is  a  pleasant  and  disinfectant  drink. 
Of  albuminoids,  peptones,  and  "  peptonoids,"  and  of  beef- 
juice,  only  a  certain  quantity  is  digested  or  absorbed;  the 
good  that  is  to  come  from  them  is  not  from  swallowing, 
but  from  digesting.  The  lips  and  tongue  should  be  kept 
clean.  Older  children  will  wash  and  gargle.  When  the 
tongue  is  red  and  dry,  and  fissured,  one  or  two  daily  ap- 
plications may  be  made  with  a  clean  camel-hair  brush,  of 
a  one  or  two  per  cent,  solution  of  nitrate  of  silver.  The 
nose  should  be  kept  clean,  washed  out  with  normal  salt 
solution  in  urgent  cases.  To  guard  against  hypostasis  of 
the  lungs  and  the  cord,  the  posture  in  bed  should  be 
changed  from  time  to  time. 

A  purgative  dose  of  calomel  in  the  very  beginning  will 
act  beneficially  not  so  after  the  second  half  of  the  first 
week  when  diarrhea  and  hemorrhages  may  be  caused  by  it. 
Constipation  requires  warm  water  enemata  daily;  diarrhea, 
frequent  irrigations  with  water'  of  from  95  to  100°  F. 
When  the  discharges  are  offensive,  thymol,  or  perman- 
ganate of  potassium  may  be  added  in  a  proportion  of  1 :3,- 
000-4,000.  Internally,  bismuth,  sulpho-carbolate  of  zinc, 
salol,  naphthalin  are  indicated.  Bronchial  catarrh  demands 
no  special  treatment  in  most  cases ;  if  the  secretion  is 
viscid,  and  dyspnea  present  from  that  cause,  camphor  is 
serviceable.  Collapse  requires  strong  stimulants,  by  mouth 
and  sub-cutaneously ;  diluted  alcohol,  camphor  in  sweet  al- 
mond oil  1 :  4,  and  the  salicylate  or  benzoate  of  sodium 
and  caffein,   soluable  in  two  parts   of  water,  answer  best 

318 


TYPHOID    FEVER    IN    THE    YOUNG 

for  that  purpose.  Insomnia,  great  excitement,  and  con- 
secutive psychoses  may  require  chloral  hydrate.  When  the 
heart  is  feeble,  croton  chloral  should  be  selected  instead. 
When  these  symptoms  are  accompanied  with  heat  of  the 
head,  cold  applications  to  the  head,  ice  water,  ice  bags 
are  soothing.  The  head  should,  under  such  circumstances, 
be  kept  as  high  as  comfort  permits.  Sopor  or  coma  should 
be  treated  with  cold  affusions,  while  the  body  is  submerged 
in  water  of  90  or  95  degrees. 

Is  it  desirable  to  resort  to  antipyretic  treatment?  If 
so,  in  what  class  of  cases,  mild,  medium  or  grave?  This 
latter  classification,  however,  should  not  exist,  for  the  ap- 
parently mild  case  may  turn  out  to  be  a  grave  one.  Or  is 
it  desirable  to  allow  high  temperatures  to  persist? 

The  vis  medicatrix  naturae  has  been  eulogized  in  infec- 
tious fevers.  However,  the  wholesome  influence  of  intense 
body  heat  on  bacteria  and  toxins  has  become  very  doubt- 
ful, and  good  observers  like  Fliigge  deny  the  new  gospel 
of  the  increase  of  phagocytosis  by  high  temperatures  ab- 
solutely. Nor  is  the  disintegration  of  tissues  by  heat  alone 
successfully  contradicted.  Thus,  after  all,  we  need  not  en- 
joy the  presence  of  high  temperatures  as  a  blessing,  dis- 
guised or  undisguised,  and  should  reduce  them.  This 
much  is  certain,  that  the  comfort  of  the  patient  is  enhanced, 
and  grave  nervous  symptoms  alleviated,  when  the  hot,  dry 
skin  becomes  cooler  and  moist  in  proportion  to  the  reduc- 
tion of  the  general  temperature. 

Which  are  the  means  by  which  we  can  effectually  obtain 
it?  The  number  of  antiferbrile  medicaments  has  grown 
immeasurably;  the  cautious  practitioner  will  do  well,  how- 
ever, not  to  embark  in  the  dark  sea  of  unknown  territories, 
guided  by  nothing  but  the  flashlight  advertisements  of  the 
drug  manufacturer.  Some  of  the  new  remedies  are  actual 
dangers.  Acetanilid  is  a  poison  like  all  anilins;  it  changes 
hematin  into  methemoglobin,  and  thus  cause  the  cyanosis 
that  is  so  frequently  noticed.  Antipyrin  is  perhaps  the 
safest;  sodium  salicylate  annoys  the  stomach  and  the  kid- 
neys, which  are  very  liable  to  suffer  from  the  typhoid  toxin 
alone.  Quinine  acts  well  during  intermissions  and  re- 
missions, not  however  when  high  temperatures  are  continu- 

319 


DR.    JACOBI'S    WORKS 

ous.  The  cardiac  stimulants — digitalis,  strophanthus,  spar- 
tain,  camphor,  alcohol — which  improve  the  general  and  cu- 
taneous circulation,  and  thereby  the  radiation  of  heat  from 
the  skin,  are  mighty  weapons  in  the  hands  of  the  intelli- 
gent medical  adviser,  who  moreover  need  not  limit  himself 
to  the  few  remedies  I  mentioned. 

All  of  these  remedies,  however,  do  not  exhaust  our  re- 
sources ;  indeed  they  are  only  of  minor  importance.  With- 
out knowing  all  of  it  the  old  poet  exclaimed  "  hudor  aris- 
ton,"  the  water  is  the  best.  Cold  water  and  warm  water 
are  our  most  reliable  and  at  the  same  time  the  safest  anti- 
pyretics. Stress  should  be  laid  on  the  latter  title,  because 
many  of  the  very  apostles  of  hydrotherapy,  perhaps  in- 
fluenced by  shaky  phagocytosis  and  toxin  theories,  belittle 
it  in  comparison  with  the  nerve  stimulating  powers  of 
water.  Now,  cold  bathing  is  frequently  contraindicated;  it 
is  not  borne  when  the  heart  is  feeble  from  whatsoever  cause ; 
for  instance,  long  duration  of  the  disease,  complications 
with  pneumonia,  peritonitis,  or  hemorrhages,  previous  bad 
health  or,  in  the  adult,  excesses.  No  stimulant  given  before 
or  during  the  procedure  is  certain  to  counteract  the  par- 
alyzing effect  on  the  peripheral  circulation.  When  after 
a  cold  bath  the  feet  remain  cold  and  the  pulse  small, 
the  bath  was  contraindicated,  and  did  harm.  The  patients 
in  public  hospitals  are  quite  often  of  a  low  vitality,  and 
feel  the  cold  bath  as  a  shock;  at  all  events,  most  of  those 
who  arrive  in  the  hospital  after  a  week  or  two  have  passed 
the  time  when  the  cold  bath  might  have  done  good.  Of 
this  nature  is  the  latest  experience  of  I.  Rudisch  in  the 
Mount  Sinai  Hospital  (Mt.  S.  Rep.,  Vol.,  1899).  He  says: 
"  The  Brand  treatment  reduced  the  mortality  a  little  over 
2  per  cent.  This  reduction  occurred  in  the  cases  which 
had  been  sick  two  weeks  or  longer,  outside  the  hospital. 
Since  the  introduction  of  the  Brand  treatment  there  has 
been  an  increase  in  the  number  of  cases  of  pneumonia  and 
phlebitis,  and  a  decrease  of  those  of  furunculosis  and 
nephritis.  Relapses  have  increased  2.5  per  cent.  The 
death  rate  in  the  relapse  cases  before  and  since  the  in- 
troduction of  the  Brand  treatment  is  practically  the  same. 
It  hag  not  reduced  the  number  of  complicated  cases  as  a 

820 


TYPHOID    FEVER    IN    THE    YOUNG 

whole,  but  has  decreased  the  number  of  deaths  from  toxe- 
mia in  the  causation  of  the  mortality  of  typhoid   fever." 

This  does  not  speak  well  for  the  indiscriminate  use  of 
cold  water  for  hospital  patients. 

The  dangers  of  cold  bathing  are  not  encountered  in  warm 
bathing.  This  is  not  the  place  to  prove  for  the  thou- 
sandth time  that  a  bath  of  95°  or  90°  F.  when  of  suffi- 
cient, even  when  of  short  duration,  will  reduce  a  tempera- 
ture of  104-°  or  106°.  It  is  simply  a  fact.  Such  a  bath 
may  easily  be  given  every  three  or  five  hours;  even  ap- 
parently mild  cases  should  have  two  or  three  daily,  from 
the  beginning  to  the  end  of  the  illness.  They  reduce  the 
temperature,  the  accompanying  frictions  stimulate  the  cu- 
taneous and  general  circulation,  the  general  condition  is 
improved,  the  so-called  typhoid  state  relieved,  and  re- 
lapses become  less  frequent.  Warm  bathing  should  be  the 
principal  treatment  of  all  typhoid  fevers,  not  to  the  ex- 
clusion, however,  of  occasional  medication  calculated  to 
have  similar  effects.  The  combination  of  frequent  and 
protracted  bathing  with  proper  medication  will  always  re- 
main appropriate,  though  our  resources  should,  as  we  ex- 
pect, be  increased  by  serotherapy.  The  searching  for  it, 
and  the  frequent  insufficiency  of  medication  in  skilful  or 
unskilled  hands,  both  by  thoughtful  or  routine  practi- 
tioners, have  caused  us  too  often  to  neglect  our  most  ac- 
tive helps.  Even  where  serotherapy  has  scored  its  most 
deserved  laurels,  for  instance,  in  diphtheria,  the  almost 
boastful  limitation  to  the  use  of  antitoxin,  to  the  exclusion 
of  other  internal  and  external  treatment,  is  a  mistake. 
What  is  to  be  treated  is  not  the  bacillus,  but  the  organism 
invaded  by  the  bacillus;  and  the  clinician  should  know  that 
bacteriology  is  an  indispensable  aid  to  clinical  medicine, 
but  not  clinical  medicine  itself.  Thus,  when  we  shall  find 
an  antitoxin  for  the  typhoid  bacillus,  we  shall  still  require 
adjuvant  treatment  for  the  typhoid  man,  woman  and  child. 


821 


ANEMIA  IN  INFANCY  AND  EARLY  CHILD- 
HOOD 

Pathological  processes  are  but  the  utterances  of  physi- 
ological functions  performed  under  abnormal  circumstances. 
Those  functions  depend  on  the  anatomical  condition  of 
the  tissues  or  organs.  While  this  relation  has  long  been 
established  in  the  minds  of  medical  men,  the  former, 
though  acknowledged  theoretically,  is  frequently  not 
heeded.  As  a  rule,  the  pathological  anatomy  of  a  dis- 
eased organ  is  stated,  in  connection  with  the  history  of 
a  case,  or  the  description  of  a  class  of  cases,  but  the 
reference  of  an  anatomical  predisposition  of  tissues  or 
organs  to  special  morbid  processes  is  mostly  neglected. 
It  is  mainly  Beneke  who  has  studied  disease  from  this 
point  of  view,  and  it  is  from  his  various  essays  and  works 
on  kindred  subjects  that  some  of  the  exact  data  to  be 
laid  before  you  are  taken. 

By  rights,  every  treatise,  essay  or  paper  on  a  pathologi- 
cal subject  ought  to  commence  with  the  normal  anatomical 
condition  of  the  organ  or  tissue  to  be  dealt  with.  Thus, 
only,  an  intelligent  appreciation  of  the  facts  becomes  pos- 
sible, and  thus,  only,  when  every  case  is  viewed  in  this 
light,  the  practice  of  a  medical  man  is  raised  above  the 
level   of   routine   and   drudgery. 

When,  some  time  ago,  Mr.  President,  I  had  the  honor 
of  reading  before  our  Society  a  paper  on  infant  diarrhoea 
and  dysentery,  I  emphasized  the  fact  that  healthy  infants 
have  a  normal  tendency  to  loose  liquid  or  semi-fluid  evacu- 
tions  from  the  bowels.  The  causes  I  stated  to  lie  partly 
in  the  conditions  of  the  intestinal  tract,  and  partly  in  the 
nature  of  the  normal  food,  viz.,  breast  milk.  The  latter 
do  not  concern  us  now,  but  the  former  I  repeat  merely  for 
the  purpose  of  establishing,  in  a  few  examples,  the  close 
connection  between  anatomical  structure  and  physiological 

323 


DR.    JACOBI'S    WORKS 

and  pathological  conditions.  The  peristaltic  movements 
in  the  infantile  intestine  are  very  active;  the  young  blood- 
vessels very  permeable;  the  transformation  of  surface  cells 
is:  very  rapid.  The  peripheric  nerves  lie  very  superficially, 
more  so  than  in  the  adult,  whose  mucous  membranes  and 
submucous  tissues  have  undergone  thickening  by  both  nor- 
mal development  and  morbid  processes.  In  the  infant, 
the  peripheric  ends  of  the  nerves  are  larger  in  proportion 
than  in  the  adult,  the  anterior  horns  of  the  nerve  cen- 
tres more  developed  than  the  posterior  ones.  Thus,  the 
great  reflex  irritability  of  the  young,  under  intestinal  and 
other  influences,  is  easily  explained.  Besides,  the  action 
of  the  sphincter  ani  is  not  quite  powerful,  the  faeces 
are  not  retarded  in  the  colon  and  rectum,  and  no  time  is 
aff'orded  for  the  re-absorption  of  the  liquid  or  dissolved 
constituents  of  the  faeces.  Moreover,  the  frequent  occur- 
rence of  acids,  sometimes  in  normal  conditions,  in  the 
small  intestines,  gives  rise  to  the  formation  of  alkaline 
salts  with  purgative  properties. 

On  the  other  hand,  constipation  in  the  very  young  is 
sometimes  the  result  of  grossly  anatomical  conditions  of 
the  intestinal  tract.  I  should  not  have  to  allude  to  the 
fact  at  the  present  time  if  it  were  not  for  the  following 
reasons:  Firstly,  this  form  of  constipation  illustrates  ex- 
ceedingly well  the  connection  between  anatomy  and  func- 
tion; secondly,  the  routine  treatment  of  constipation  by 
the  administration  of  purgatives  would  be  very  dangerous 
in  just  such  a  case;  and  lastly,  what  I  have  published  about 
the  subject  more  than  ten  years  ago,  and  repeated  in 
the  treatise  on  hygiene,  edited  by  Dr.  A.  Buck,  appears 
not  to  have  been  noticed  to  such  an  extent  that  the  suf- 
fering infants  can  be  sufficiently  benefited.  At  least,  in  an 
essay  on  constipation,  published  but  lately  and  presumably 
considered  complete  in  its  etiology,  this  important  cause 
of  the  most  obstinate  form  of  constipation  in  the  very 
young  is  not  mentioned  at  all. 

It  therefore  bears  repetition ;  it  is,  in  a  few  words,  as 
follows:  Until  the  fourth  or  fifth  months  of  foetal  life, 
there  is  no  colon  ascendens,  and  it  is  still  short  at  birth. 
Notwithstanding   that    fact,    the    large    intestine    at   birth 

324 


ANiEMIA    IN    CHILDHOOD 

is  comparatively  longer  than  that  of  the  adult.  While 
in  the  infant  it  is  nearly  three  times  the  length  of  the 
entire  body,  it  is  but  twice  that  length  in  the  adult.  Now, 
the  colon  ascendens  is  very  short  in  the  newborn,  the 
transverse  colon  is  not  much  longer;  thus,  the  main  part  of 
the  excessive  length  belongs  to  the  colon  descendens,  and 
inainly  to  the  sigmoid  flexure,  which  Brandt  found  from 
fourteen  to  twenty  centimetres,  and  myself  in  one  case 
thirty  cm.  in  length.  This  exorbitant  length  of  the  sig- 
moid flexure  at  tlie  entrance  of  the  narrow  pelvis,  gives 
rise  to  more  than  the  simple  curve  found  in  the  adult. 
Not  infrequently  the  main  curve  is  found  on  the  right 
side  instead  of  the  left,  and  sometimes  the  repeated 
bending  upon  itself  of  the  elongated  gut  is  such  as  to 
seriously  retard,  and  in  a  few  instances  prevent,  the  pas- 
sage of  faeces. 

The  two  instances  hitherto  spoken  of  illustrate  the  close 
connection  of  two  conditions  noticed  in  very  early  life 
depending  upon  the  anatomical  structure  of  the  affected 
organ.  In  brief,  I  shall  allude  to  two  others  which  be- 
come manifest  at  a  little  later  period  of  infant  life.  Thus, 
in  rhachitis,  while  the  heart  is  of  average  size,  the  arteries 
are  abnormally  large,  tlie  liver  is  of  extraordinary  volume, 
and  the  lungs  are  small.  Great  width  of  arteries  lowers 
the  pressure  of  the  blood.  One  of  the  results  of  this 
physiological  fact  is  the  murmur  audible  in  the  brain  of 
rhachiticial  babies,  which,  by  no  means,  as  Jurasz  ex- 
plained it,  results  from  the  anomalies  of  the  carotic  canal. 
Another  result  of  the  low  blood  pressure  is  the  retarda- 
tion of  the  circulation  in  the  muscles,  and  more  yet  about 
the  epiphyses,  which  swell  and  soften.  It  is  not  the  growth 
of  the  epiphyses  alone  which,  by  itself,  results  in  general 
rhachitis,  for  the  epiphyses  are  still  in  their  cartilaginous 
condition  up  to  adolescence,  and  some  do  not  ossify  until 
the  twentieth  year  of  life;  but  no  rhachitis  is  met  with  at 
this  advanced  stage.  Thus  it  is  by  no  means  the  anatomi- 
cal condition  of  the  cartilaginous  tissue  which  is  one  of 
the  causes  of  rhachitis,  but  the  condition  of  the  arteries 
supplying  the  epiphyses.  Besides,  the  large  size  and  active 
condition  of  the  liver  give  rise  to  a  copious  formation  of 

325 


DR.    JACOBI'S    WORKS 

cholestearin,  the  importance  of  which,  in  the  establishment 
of  a  hyperplastic  condition  of  cartilage  cells  and  tissue 
elements  in  general,  has  long  been  recognized.  Thus,  os- 
sification becomes  irregular  and  defective,  and  the  rhachiti- 
cial  bone  contains  an  abnormally  large  quantity  of  fat,  in 
contrast  with  the  deficient  percentage  of  lime,  which  either 
is  not  introduced  or  not  assimilated  in  consequence  of  the 
faulty  nature  of  the  preliminary  stages  of  osseous  de- 
velopment. 

Some  other  peculiarities  are  found  in  the  condition  which 
has  been  called  scrofula.  The  normal  relation  of  the  heart 
to  the  lungs,  between  the  second  and  twentieth  years,  is 
1 :  5-7;  in  scrofula  it  is  1 :  8-10.  This  circumstance,  coupled 
with  an  acquired  debility  of  the  nervous  system,  results  in 
an  insufficient  supply  of  blood  to  both  lungs  and  organism, 
and  defective  oxygenation,  particularly  in  those  cases  which 
by  common  consent  have  been  called  torpid  scrofula.  It 
is  mainly  in  these  that  the  lymphatic  system  pre-emi- 
nently participates  in  the  symptoms.  The  size  and  number 
of  the  lymphatics  are  very  great  in  infancy.  Sappey 
found  that  they  could  be  more  easily  inj  ected  in  the  child 
than  in  the  adult,  and  the  intercommunication  between 
them  and  the  general  system  is  more  marked  at  that 
than  any  other  period  of  life.  These  facts  are  but  lately 
verified  by  S.  L.  Schenck,  who,  moreover,  found  the  net- 
work of  the  lymphatics  in  the  skin  of  the  newly-born  en- 
dowed with  open  stomata,  through  which  the  lymph-ducts 
can  communicate  with  the  neighboring  tissues  and  cells, 
and  vice  versa  (Jacobi,  "  Treat,  on  Diphth.,"  p.  31). 

The  blood  of  the  newborn  differs  greatly  from  that 
of  the  infant  at  a  period  but  little  advanced.  The  haemo- 
globulin  in  the  umbilical  artery  amounts  to  22.2  per  cent, 
of  the  whole  solid  constituents,  while  in  the  venous  blood 
of  the  mother  it  is  but  13.99  per  cent.  The  first  to  prove 
this  high  percentage  was  Denis,  in  1830,  who  found  the 
correct  proportions  by  determining  the  quantity  of  iron 
contained  therein.  Poggiale  found  a  similar  proportion  of 
the  haemoglobulin  in  the  newborn  and  the  fully-grown 
dog,  viz.,  16.5:  12.6  per  cent.,  and  Wiskeman's  results 
are  similar.      The  total  amount  of  the  blood  contained  in 

326 


ANEMIA    IN    CHILDHOOD 

the  newborn  is,  however,  smaller  than  in  the  adult,  the 
relation  of  its  weight  to  the  total  weight  of  the  body  being 
in  the  former,  1 :  19-5;  in  the  latter,  1 :  13. 

These  conditions,  however,  are  being  changed  soon.  The 
high  percentage  of  haemoglobulin  commences  to  decrease 
instantly.  Young  animals  have  less  than  old  ones;  in  the 
calf  and  oxen  the  proportion  is  11.13:  13.21. 

Denis  found  it  to  diminish  until  the  age  of  six  months, 
and  a  very  slow  increase  up  to  the  thirtieth  year.  Leich- 
tenstern  found  the  following  proportions:  if  the  blood  of 
the  newborn  contains  haemoglobulin  100,  that  of  a  child 
of  from  six  months  to  five  years  contains  55 ;  of  from  five 
to  fifteen  years  58.  At  the  age  of  from  fifteen  to  twenty- 
five  it  is  64,  25-45^72,  and  45-60  it  is  63.  Subotin  also 
found  less  in  young  animals  than  in  old  ones;  also  less 
when  the  amount  of  nitrogenous  food  was  reduced.  Leich- 
tenstern  found  the  percentage  of  haemoglobulin  to  decrease 
in  the  very  first  two  weeks.  It  was  lowest  at  the  age 
of  from  six  months  to  six  years ;  after  that  time  a  slow  in- 
crease takes  place.  But  even  in  the  very  vigor  of  life,  in 
the  third  and  fourth  decennia,  the  percentage  of  haemo- 
globulin is  smaller  than  in  the  newborn. 

There  are  some  more  differences  in  the  composition  of 
the  blood  of  the  young,  more  or  less  essential  in  character. 
The  foetal  blood  and  that  of  the  newborn  contains  but 
little  fibrine,  but  vigorous  respiration  works  great  changes 
in  that  respect.  Nasse  found  the  blood  of  young  animals 
to  coagulate  but  slowly.  How  this  is  in  the  infant  cannot 
be  determined  until  more  and  better  observations  will  have 
been  made.  There  are  less  salts  in  the  blood  of  the  young, 
and  according  to  Moleschott,  more  leucocytes.  Its  specific 
gravity  in  the  young  is  1045-1049;  in  the  adult,  1055. 
Thus,  letting  alone  the  newborn,  the  result  from  the 
above  figures  is  this:  The  infant  and  child  has  and  re- 
quires more  blood  in  proportion  to  its  entire  weight,  but 
this  blood  has  less  fibrine,  less  salts,  less  haemoglobulin, 
less  soluble  albumen,  more  white  blood  corpuscles,  and 
less  specific  gravity. 

The  large  arteries  in  the  newborn  and  the  infant  are 
wide,  and  consequently  the  blood  pressure  is  but  low.    This 

327 


Dll.    JACOBI'S    WORlCS 

Is  mainly  so  in  the  first  five  years,  in  the  subclavian  and 
common  carotid.  Thus  the  brain  has  a  chance  to  grow 
from  400  grammes  to  800  in  one  year;  after  that  period 
its  growth  becomes  less.  At  seven,  boys  have  brains  of 
1100,  girls  of  1000  grammes.  In  more  advanced  life  its 
weight  is  relatively  less;  1424  in  the  male,  and  1272  in 
the  female.  At  the  same  early  period  the  whole  body 
grows  in  both  length  and  weight.  The  original  50  cm. 
of  the  newly-born  increase  up  to  110  with  the  seventh 
year;  the  greatest  increase  after  that  time  amounting  to 
60  (in  the  female,  50)  centimetres  only.  In  the  same 
time  the  weight  increases  from  3.2  kilo,  to  20.16  in  the 
boy;  from  2.9  to  18.45  in  the  girl;  a  proportion  of  1  to 
6  or  'J,  while  after  that  time  the  increase  is  but  three- 
or   four-fold. 

As  the  organs  grow,  so  do  the  peripherous  blood-vessels. 
Their  size  is  in  proportion  to  the  large  blood-vessels. 
Only  the  heart  grows  toward  the  seventh  year,  perhaps, 
only  because  it  requires  an  over-exertion  to  overcome  the 
sluggishness  in  the  circulation  of  the  large  and  small 
blood-vessels.  It  is  smallest,  with  large  arteries,  in  the 
first  year  (particularly  in  the  second  half)  at  the  same 
time  that  the  growth  is  most  intense.  Thus  it  appears  that 
the  growth  and  physiologically  low  blood  pressure  go 
hand  in  hand. 

The  sizes  of  the  large  blood-vessels  do  not  grow  equally, 
nor  do  they  exhibit  the  relative  proportions  to  each  other 
of  the  normal  development  of  the  adult.  The  pulmonary 
artery  is  from  two  to  four  centimetres  larger  than  the 
descending  aorta.  That  means  for  the  lungs  more  active 
work,  but  also  more  tendency  to  disease,  particularly  as, 
since  the  closure  of  the  ductus  Botalli,  the  aorta,  from 
which  the  bronchial  arteries  are  sent  off,  assumes  con- 
siderable proportions  within  a  short  space   of  time. 

At  this  time  the  lungs  begin  to  rival  the  liver,  which  in 
the  first  days  of  life  was  twice  as  large  as  both  lungs 
combined.  At  this  time,  the  amount  of  carbonic  acid 
eliminated  by  the  lungs  is  increasing  steadily  to  relative 
proportions  not  known  in  the  adult,  in  the  same  manner  as 
the  amount  of  urea  eliminated  is  relatively  larger  than  in 

328 


ANiEMIA    IN    CHILDHOOD 

the  adult,  in  consequence  of  the  size  of  the  kidneys,  which 
are  proportionately  larger  than  in  the  adult. 

Water  prevails  in  the  organs,  even  to  a  greater  extent 
than  the  smaller  specific  gravity  of  the  blood  appears  to 
justify.  The  brain  in  all  its  parts,  but  not  equally  in  all, 
contains  a  high  percentage  of  water,  the  exact  figures  of 
which  can  be  found  in  "  Buck's  Hygiene,"  1st  vol.,  p.  139. 
The  muscular  tissue  has  a  percentage  of  81.8  (E.  Bischof) 
in  the  newborn;  of  78.7  in  the  adult.  Schlossberger 
found  the  following  figures:  in  a  calf  of  four  weeks  79.7; 
the  grown-up  animal,  77;  the  young  duck,  85.4;  the  old  72. 

The  labor  required  of  both  heart  and  lungs  is  greater 
than  in  the  adult;  thus  fatigue  is  more  easily  experienced, 
and  the  necessity  of  sleep,  the  interruption  or  absence  of 
which  adds  to  the  exhaustion  and  waste,  is  readily  ex- 
plained. More  physiological  work  is  done  by  these  two 
organs,  and,  moreover,  in  a  manner  somewhat  different 
from  what  we  notice  in  the  fully  developed  individual.  In 
him,  nothing  is  required  but  the  sustenance,  or  rather, 
constant  reproduction  of  the  bulk  of  the  body;  in  the  child, 
not  only  reproduction,  but  a  new  development  of  tissues, 
a  constant  growth,  must  go  on. 

Within  one  year  after  birth,  the  young  creature  attains 
three  times  its  original  weight.  Thus  we  have  to  deal 
with  a  being  whose  organs  are  in  constant  exertion,  or  al- 
most over-exertion.  Now,  metamorphosis  of  matter  is  not 
controlled  by  the  inhaled  oxygen  alone,  for  the  living 
organism  is  not  only  what  Liebig  took  it  to  be,  an  oven; 
its  intensity  depends  certainly  in  part  on  nerve  influences. 
As  the  nerve  cells  contain  so  much  more  water  than  in  later 
periods  of  life,  it  is  very  probable  that  their  electro-motor 
action  differs  from  that  exhibited  later  on.  Besides,  the 
predominating  development  of  the  medulla  oblongata,  the 
anterior  horns  and  trophic  nerves,  points  to  the  same  con- 
clusions. All  this  action  and  activity  is  at  the  expense  of 
the  system.  But  that  is  not  all.  Not  only  exertion  and 
almost  over-exertion,  when  compared  with  the  efforts  of 
the  merely  self-sustaining  adult  system,  but  constant  pro- 
duction of  new  material,  and  all  this  at  the  expense  of  a 
blood  which  contains  less  solid  constituents  than  the  blood 

329 


BR.    JACOBI'S    WORKS 

of  the  old.  Thus  the  normal  oligaemia  of  the  child  is  in 
constant  danger  of  increasing  from  normal  physiological 
processes.  The  work  before  a  baby  has  to  be  performed, 
under  the  most  favorable  circumstances,  with,  so  to  speak, 
a  scarcely  sufficient  capital.  The  slightest  mishap  reduces 
the  equilibrium  between  that  capital  and  the  labor  to  be 
performed,  and  the  chances  for  the  diminution  of  the 
amount  of  blood  in  possession  of  the  child  are  very  fre- 
quent indeed. 

Thus,  the  vulnerability  of  the  young  being  great,  and 
diseases  in  early  infancy  and  childhood  so  very  frequent, 
cases  of  anaemia  are  met  with  in  every  day's  practice,  and 
in  every  form,  complicated  and  uncomplicated,  with  great 
emaciation  or  without  it,  and  either  curable  or  not.  A 
condition  so  frequent,  so  variable,  so  dangerous,  deserved 
to  be  treated  in  monographs  by  the  best  men  amongst 
practitioners  and  writers,  and  still  there  is  scarcely  any 
text-book,  any  journal,  in  which  a  competent  and  compre- 
hensive view  of  the  subject  can  be  found.  There  is  but 
one  noteworthy  exception  to  this  fact.  Dr.  Forster,  of 
Dresden,  contributed  two  years  ago  a  valuable  essay  on 
the  subject  in  one  of  the  most  praiseworthy  literary  under- 
takings of  modern  medical  authorship.  There  are  two 
great  works  in  paediatric  literature  recognizable  as  land- 
marks. The  first  were  the  three  volumes  of  monographs 
published  by  Rilliet  and  Barthez.  The  second  is  the  great 
manual  on  diseases  of  children,  edited  by  C.  Gerhardt.  In 
its  third  volume  Dr.  Forster's  article  has  been  published. 
Like  others  before  him,  he  makes  a  distinction  between 
idiopathic  and  symptomatic  anaemia. 

The  former  diagnosis  is  made  when  there  is  no  tangible 
cause  at  all,  or  none  which  still  persists;  the  latter  when 
the  change  in  the  blood,  with  all  its  consequences,  is  at- 
tributable to  a  previous  or  present  sickness.  Perhaps  it  is 
idle  to  consider  the  question  at  all,  whether  there  can  be 
a  genuine,  primary  idiopathic  anaemia.  When  we  sift  the 
matter,  we  shall  come  to  the  simple  conclusion  that  every- 
thing has  its  cause,  is  but  a  result,  and  secondary  to  some- 
thing else.  From  this  point  of  view,  and  strictly  speaking, 
objection    could   be   raised   to   the   term   idiopathic    pneu- 

S80 


ANvEMlA    IN    CHILDHOOD 

monia,  peritonitis,  or  meningitis.  When  we  make  use  of 
it,  we  mean  to  state  only  that  the  local  affection  is  no 
longer  complicated  with  any  other  that  could  be  diagnos- 
ticated, and,  possibly,  removed. 

In  this  sense  there  are  cases  of  idiopathic  anaemia,  in 
which  the  original  infant  disposition  to  it,  of  physiological 
character,  has  been  raised  to  a  pathological  dignity.  But 
the  large  majority  of  cases  are  of  markedly  secondary  char- 
acter, and  cannot  be  appreciated  or  treated  rationally  with- 
out the  recognition  of  the  original  causes.  They  are  of 
the  most  various  character.  In  fact  every  disease  occur- 
ring in  infancy  and  childhood  may  give  rise  to  anaemia. 
Very  few  diseases  when  they  have  run  their  full  course 
and  terminated  in  what  we  are  pleased  to  call  recovery, 
leave  the  organism  or  the  affected  organ  in  as  perfectly 
a  normal  condition  as  previously.  The  frequent  recur- 
rence of  simple  diseases  such  as  pneumonia  points  to  the 
fact  that  changes  have  been  worked  which  create  a  con- 
stant predisposition  to  pathological  processes  in  the  same 
organ.  Thus,  in  most  cases  of  anaemia  the  diagnosis 
of  the  whole  case  must  extend  to  the  organ  first  affected, 
and  the  treatment,  while  it  may  be  directed  against  the 
result,  is  incomplete  unless  the  causal  indications  be  ful- 
filled. 

Hemorrhages  result  in  anaemia  in  a  number  of  instances. 
They  are  of  different  character  and  importance.  There  is 
true  melaena;  umbilical  hemorrhage;  hemophilia;  primary 
or  secondary  purpura;  internal  hemorrhages  of  the  new- 
born; cephalhaematoma ;  hemorrhages  from  rectal  polypi; 
epistaxis  depending  on  coryza;  epistaxis  at  a  more  ad- 
vanced age  from  heart  disease  and  abdominal  stagnation; 
hemorrhages  in  diphtheritic  angina;  and  such  as  take  place 
during  or  in  consequence  of  operations  for  hare-lip  or 
ritual  circumcision.  Death  may  result  from  many  of  them, 
such  as  melaena,  hemophilia,  pharyngeal  hemorrhages,  or 
circumcision;  others  are  of  but  little  gravity,  such  as  the 
sanguineous  tumor  of  the  newborn;  others  are  apt  to 
result  in  permanent  ailing.  As  a  rule,  however,  an  acute 
anaemia  is  more  easily  overcome  than  one  that  is  of  a 
more  chronic  nature,  and  thereby  undermines  the  vitality 

831 


DH.    JACOBl'S    WORKS 

and  strength  of  the  organs  while  it  slowly  robs  them  of 
their  nutriment.  Infants  who  are  thus  stricken  recover 
but  slowly  or  not  at  all.  Young  animals  resist  starvation 
to  a  less  degree  than  old  ones.  A  dog  of  two  days  bore 
starvation  in  Magendie's  laboratory  but  two  days;  a  dog 
of  six  years,  thirty.  Similar  results  were  obtained  by 
Chossat  in  his  experiments  on  pigeons.  Thoroughly  anaemic 
and  delicate  babies  seldom  recover  entirely,  like  starving 
young  animals  which  never  attained  their  normal  condi- 
tion though  they  were  carefully  fed  afterward.  The 
recruits  of  the  Prussian  army  born  in  the  starvation  years 
of  1816  and  1817  were  of  a  very  inferior  character  physi- 
cally. To  this  class  also  belong  the  children  born  prema- 
turely and  of  delicate  parentage,  though  there  were  no 
recognizable  constitutional  disease,  and  of  mothers  afflicted 
with  a  disease  of  the  uterus  or  placenta,  inflammatory, 
syphilitic,  or  otherwise;  or  of  such  as  suff'ered  much 
during  pregnancy  or  lactation;  also  those  born  with  con- 
genital diseases,  cyanosis,  or  neoplasms,  which  are  by  no 
means  so  rare  as  has  often  been  believed  and  said,  or  the 
peculiar  smallness  of  the  heart,  and  principally  the  ar- 
teries, to  which  Virchow  attributes  many  cases  of  chlorosis. 
I  have  met  with  half  a  dozen  of  such  cases,  in  which 
the  supply  of  blood  to  the  body  was  diminished  by  this 
anomaly,  and  Dr.  Skene  reported  a  case  of  probably  the 
same  nature  which  was  published  in  the  Journal  of  Ob- 
stetrics and  Diseases  of  Women  and  Children,  Oct.,  1876. 

Besides  the  diseases  and  affection  of  the  newborn 
there  are  others  which  develop  in  later  life  and  lead  to  the 
same  results.  It  is  often  acquired  in  endocarditis,  for 
instance;  acute  inflammatory  rheumatism,  which  is  very 
frequent,  yields  in  most  cases  but  little  swelling  of  the 
joints,  comprises  most  cases  of  so-called  growing  pain, 
and  has  a  much  more  marked  tendency  to  the  production 
of  an  endocarditis  than  the  same  afl"ection  in  the  adult. 

Protracted  diarrhoea  injures  to  a  greater  extent  than  con- 
stipation. It  acts  not  only  by  direct  and  immediate  loss 
of  serum,  through  which  it  can  prove  fatal  in  a  short 
time,  but  more  frequently  by  its  consequences.  The 
mucous    membrane   of   the   intestinal   tract   becomes   thick- 

SS2 


ANEMIA    IN    CHILDHOOD 

ened,  the  submucous  tissue  oedematous,  the  muscular  layer 
oedematous  or  hyperplastic;  the  adventitia  sometimes  im- 
dergoes  fatty  degeneration.  Erosions  and  ulcerations  are 
apt  to  become  chronic,  and  frequently  the  n^esenteric 
glands  are  the  seats  of  congestive  and  hyperplastic  proc- 
esses. An  intestinal  catarrh  cannot  last  any  length  of  time 
without  irritating,  congesting,  enlarging,  and  finally  in- 
durating, or  provoking  caseous  degeneration  of  the  neigh- 
boring lymphatic  glands.  The  cause  of  the  diarrhoea  is 
indifferent  in  this  respect.  None  can  last  without  con- 
secutive injury  to  the  lymphatic  glands  which  is  apt  to 
become  permanent  and  deteriorate  sanguification  for  the 
future.  The  unmistakable  practical  conclusion  from  this 
fact  is  that  every  diarrhoea  must  be  stopped  as  soon  as 
possible.  Neither  summer  heat,  nor  that  great  scapegoat 
• — dentition — must  be  permitted  to  yield  a  pretext  for  the 
continuation  of  a  diarrhoea,  no  matter  how  innocent  it  may 
appear. 

Malaria,  which  is  too  often  diagnosticated  when  the  real 
nature  of  the  disease  is  not  recognized,  and  frequently 
overlooked  because  of  the  irregularity  and  the  little  pro- 
nounced character  of  the  attacks.  The  first  stage  of  the 
attack  is  often  not  recognizable.  The  attacks  are  apt  to 
come  at  irregular  times ;  are  more  quotidian  than  tertian, 
often  concealed  by  accompanying  symptoms  such  as  con- 
vulsions, and,  therefore,  sometimes  not  accessible  to  a 
ready  diagnosis.  On  the  other  hand,  the  influence  of  ma- 
laria is  apt  to  undermine  the  general  health,  render  the 
child  intensely  anaemic,  and  swell  the  spleen  considerably 
before  ever  giving  rise  to  a  real  attack. 

Nephritis,  with  albuminuria,  not  the  acute  cases,  but 
those  chronic  ones  which  slowly  undermine  the  nervous 
system  and  exhaust  by  direct  loss ;  pernicious  anaemia,  with, 
it  is  true,  as  far  as  I  know,  but  two  cases  occurring  in 
children,  recorded  in  the  literature  of  this  recent  sub- 
ject; leucocythaemia ;  sleeplessness  from  any  cause  such  as 
malaria,  whooping-cough,  or  indigestion;  mercurial  ca- 
chexia, rare  though  it  be;  congenital  or  hereditary  syphilis; 
rhachitis,  with  its  influence  on  blood  glands  and  bones,  its 
shortening^  flattening  and  even  retraction   of  the  thorax, 

333 


DR.    JACOBI'S    WORKS 

its  curvature  of  the  spine,  and  compression  of  the  lungs 
and  heart;  fatty  liver;  enlargement  of  the  lymphatic 
glands,  mesenteric,  bronchial  or  otherwise;  the  complex 
of  symptoms  comprehended  under  the  general  head  of 
scrofula;  diseases  of  the  bones  of  the  most  various  kinds, 
from  congenital  or  premature  ossification  of  the  costal 
cartilages,  with  its  consecutive  contraction  of  the  chest  and 
compression  of  its  contents,  to  the  chronic  or  subacute 
osteitis  of  the  vertebral  column  or  any  of  the  other  parts 
of  the  skeleton,  with  its  final  termination  in  amyloid  de- 
generation of  the  viscera;  and  finally,  to  conclude  with, 
diseases  of  the  lungs  and  pleurae,  caseous  deposits,  cirrhotic 
induration,  emphysema  and  empyematic  deformity. 

In  anaemia  both  the  skin  and  the  mucous  membranes  are 
pale,  of  a  yellowish  hue,  thin  and  flabby.  A  certain 
degree  of  apparent  elasticity  of  the  skin  and  subcutaneous 
tissue  is  noticed  only  in  cases  of  (Edematous  effusion. 
Those  organs  or  tissues  which  are  least  in  use  emaciate 
first;  that  is,  in  very  young  children,  fat  and  muscle. 
But  there  are  cases  in  which  fat  is  persistently  retained, 
and  in  which  it  is  often  increased  in  quantity.  For,  when 
the  red  blood  globules  are  destroyed,  there  is  scarcity  of 
oxygen,  and  for  that  reason  the  combustion  of  the  al- 
buminous substances  becomes  incomplete,  and  fat,  the 
physiological  result  of  this  incomplete  combustion,  is  de- 
posited in  large  masses.  Particularly  is  this  the  case 
when  anaemia  is  either  complicated  with  or  is  the  result  of 
general  rhachitis — when  at  the  same  time  the  glands  and 
the  chest  are  suffering  from  the  results  of  the  rhachitic 
processes.  An  illustration  of  this  peculiar  occurrence, 
which  is  by  no  means  rare,  is  also  seen  in  the  peculiar 
appearance  of  acardiac  or  acephalic  monsters,  which  con- 
tain a  large  amount  of  (Edematous  fat,  in  consequence  of 
the  exclusively  venous  character  of  their  circulation. 

In  consequence  of  the  ill  nutrition  and  the  emaciation  of 
the  muscular  tissue  these  infants  and  children  are  easily 
fatigued.  In  general,  the  functions  of  all  the  organs  suffer 
considerably.  And  with  such  debility,  irritability  goes 
band  in  hand.  The  nervous  system  is  less  affected  than 
any  other,  because  of  the  rapid  growth  and  development 


ANEMIA    IN    CHILDHOOD 

which  it  undergoes  at  that  period  of  life.  Not  infre- 
quently, babies  who  are  anaemic  and  emaciated  are  in  the 
very  best  of  spirits,  because  their  brains  are  comparatively 
in  good  condition.  A  certain  amount  of  emaciation  can 
be  easily  recognized  by  the  depression  of  the  fontanelles 
of  babies  under  one  j'ear  old  or  even  later;  but  the  emaci- 
ation of  the  brain  does  not  increase  at  a  rate  which  cor- 
responds with  the  loss  in  weight  of  the  other  organs  and 
tissues  of  the  body.  In  addition,  the  very  sinking  in  of 
the  fontanelles,  which  allows  us  to  estimate  the  amount 
of  emaciation  that  has  taken  place  inside  of  the  cranial 
cavity,  leads  us  to  the  fair  conclusion  that  the  emaciation 
of  the  rest  of  the  body  has  taken  place  to  an  unusual  ex- 
tent; and  any  baby  with  considerable  depression  of  the 
fontanelles  must  be  considered  in  danger  from  the  degree 
of  inanition  present. 

Murmurs  in  the  jugular  veins  are  not  very  frequent  in 
infancy  and  early  childhood.  Murmurs  in  the  carotids 
and  over  the  large  fontanelles,  however,  are  not  at  all 
rare.  It  is  not  true  that  these  murmurs,  audible  over  the 
brain,  belong  to  rhachitis  alone.  They  are  found  in  every 
condition  in  which  blood  pressure  in  the  large  arteries  of 
the  cranial  cavity  is  lessened. 

The  heart  itself  seldom  exhibits  functional  murmurs. 
Whenever  they  are  present,  it  is  safer  to  attribute  them 
to  organic  disease  than  to  merely  functional  disorder.  Be- 
sides, it  is  now  well  known  that  acquired  endocarditis  is 
by  no  means  rare,  and,  moreover,  that  it  occurs  even  more 
frequently  in  the  articular  rheumatism  of  the  young,  be 
it  ever  so  slight,  than  of  the  adult.  Although  the  brain 
be  not  so  liable  to  suffer  from  emaciation,  dependent  upon 
anaemia,  as  other  organs,  still  there  are  a  number  of  cases 
in  which  headaches,  attacks  of  syncope,  sleepiness,  etc.,  or, 
on  the  contrary,  sleeplessness  and  hysterical  attacks,  are 
the  result  of  anaemia  alone,  and  disappear  when  this  con- 
dition is  relieved.  Not  a  few  of  the  babies  and  children 
who  cry  the  greater  part  of  the  night  have  no  other  ail- 
ment besides  general  anaemia,  and  such  children  are  fre- 
quently relieved  by  a  meal  or  some  stimulant  before  they 
are  put  to  bed,  or  given  during  the  interruption  of  their 

335 


DR.    JACOBI'S    WORKS 

sleep.  The  pulse  of  such  children  is  sometimes  very  much 
accelerated;  sometimes,  however,  it  is  slow,  and  sometimes 
irregular.  I  have  known  such  children,  in  whom  for 
months,  and  occasionally  for  years,  I  have  feared  the  de- 
velopment of  cerebral  affections  from  the  very  fact  that 
their  pulse  was  both  slow  and  weak;  and  yet,  when  their 
general  condition  was  improved  both  the  regularity  and  fre- 
quency of  the  pulse  were  increased. 

The  pulse,  however,  is,  perhaps,  amongst  the  symptoms 
which  are  most  unreliable  at  this  age.  In  the  baby  it  is 
best  counted  during  sleep,  and  better  over  the  fontanelle 
than  upon  the  radial  artery.  It  will  change  very  fre- 
quently, not  only  with  alternate  sleeping  and  waking, 
with  rest  and  restlessness,  but  sometimes  without  apparent 
provocation.  A  slight  amount  of  muscular  action  will 
change  its  character  more  or  less,  and  frequently  consid- 
erably. Physiologically,  the  pulse  is  very  apt  to  be  more 
frequent  at  the  age  of  two  and  a  half  or  three  months 
than  earlier  or  later,  because  it  is  at  about  that  age  that 
muscular  movements  are  actually  developed. 

Very  few  anaemic  children  have  a  good  appetite  except 
at  the  beginning.  The  influence  of  anaemia  is  general  in 
regard  to  all  organs  of  the  body.  Circulation  is  deficient, 
and  the  normal  secretions  are  defective  or  deficient  in  con- 
sequence. That  is,  both  appetite  and  digestion  are  im- 
paired, and  sometimes  destroyed,  and  cannot  be  restored 
until  the  general  condition  of  the  child  is  improved. 

The  slowness  of  the  circulation  and  its  insufficiency,  and 
the  watery  condition  of  the  blood,  are  apt  to  give  rise  to 
catarrh  of  the  pharynx  and  larynx  and  the  respiratory 
organs  in  general.  Besides,  the  walls  of  the  blood-vessels 
are  known  to  suifer  in  anaemia.  They  become  thin,  and 
undergo  fatty  degeneration,  which  Ponfick  has  found  in 
the  heart,  and  in  the  intima  of  the  larger  blood-vessels 
and  in  the  capillaries.  In  consequence  of  the  thinness  of 
the  blood  and  the  changed  condition  of  the  blood-vessels, 
serous  transudation,  and,  now  and  then,  extravasations  will 
take  place.  The  same  occurrence  is  noticed  in  the  adult  in 
conditions  of  anaemia.  It  not  infrequently  occurs  that 
those  who  have  least  blood  lose  it  most  easily.     Anaemic 

336 


antEMia  in  childhood 

women  are  very  apt  to  have  copious  menstruation,  and 
when  their  general  condition  has  been  improved,  both 
blood  and  blood-vessels  resist  this  tendency  to  hemorrhage. 

There  is  one  consequence  of  the  anaemic  condition  which 
is  of  the  utmost  importance,  and  requires  urgently  that  it 
should  be   removed   in  the   shortest   possible  time. 

Whenever  a  disease  sets  in  it  is  more  liable  to  result 
fatally  in  consequence  of  impaired  powers  of  resistance, 
and  where  there  is  the  slightest  tendency  to  effusion  or  to 
exudation  these  processes  will  become  more  extensive  and 
dangerous  in  less  time  than  in  the  normal  organism.  A 
pneumonia,  a  peritonitis,  a  pleurisy,  occurring  in  an 
anaemic  child,  is  attended  with  a  great  deal  more  danger 
than  when  either  of  these  affections  occurs  in  a  child 
enjoying   good   general  health. 

That  epistaxis  in  a  child  5,  6,  or  8  years  old  should  last 
as  long  as  the  patient  is  in  a  generally  impaired  condi- 
tion, is  just  as  frequent  an  occurrence  as  it  is  a  common 
experience  to  meet  with  almost  constant  improvement  after 
a  change  of  diet,  change  of  air,  and  a  few  doses  of 
iron. 

The  predisposition  to  anaemia  in  the  child  is  very  great, 
as  proved  before,  and  the  causes  of  its  deveolpment  very 
numerous.  These  causes  must  be,  according  to  circum- 
stances, either  prevented  or  remedied.  For  genuine  cases 
of  idiopathic  anaemia  are  certainly  very  rare,  and  an  ac- 
curate diagnosis  will  find  it  to  be  symptomatic  in  almost 
every  case,  and  to  depend  on  the  lesion  of  some  organ,  or 
system  of  organs.  The  danger  of  anaemia  is  greatest  at 
the  time  of  the  most  rapid  growth,  still  it  is  a  cause  of 
slow  destruction  in  every  age.  The  nursling  is  more  ex- 
posed than  the  child,  for  the  growth  of  all  the  organs, 
with  very  few  exceptions,  is  most  intense  at  the  earliest 
period  of  life.  At  that  time,  besides  actual  disease,  insuf- 
ficient food,  or  improper  food,  are  frequent  causes,  the 
latter  a  more  frequent  one  than  the  former,  and  often  the 
more  dangerous  one  of  the  two.  Infants  whose  mothers 
or  nurses  have  not  enough  milk,  simply  starve;  they  lose 
weight,  strength  and  color.  As  long  as  their  lungs  and 
muscles  will  hold  out,  they  will  scream.     Some  of  the  yell- 

337 


DR.    JACOBI'S    WORKS 

ing  heard  in  the  night  amongst  the  tenement-house  popula- 
tion, and  sometimes  in  the  better-situated  classes,  too, 
comes  from  starving  babies.  After  a  while  the  yelling 
turns  into  a  whining,  and  any  slight  disease  terminates  the 
baby's  suffering.  This  condition  is  recognized  by  the  ab- 
sence of  local  disease  anywhere,  by  the  gradual  emacia- 
tion, and  is  characterized  by  the  paucity  of  otherwise  nor- 
mal faeces.  Many  a  case  of  alleged  constipation  is  one  of 
starvation.  Where  there  was  no  food,  there  are  no  evacua- 
tions, and  when  a  baby  is  reported  as  having  but  one  nor- 
mal passage  a  day,  or  even  less,  the  suspicion  is  that  it  has 
not  enough  to  eat.  The  remedy  is  easily  recommended, 
for  it  consists  in  nothing  but  a  sufficient  quantity  of 
proper  food. 

Improper  food  is  a  much  more  frequent  cause.  A  few 
remarks  must  suffice  here,  for  it  is  impossible  to  go  over 
the  whole  ground  of  infant  hygiene  in  a  short  paper  which 
is  more  meant  to  suggest  than  to  teach.  A  few  points, 
however,  I  must  not  omit,  because  of  the  frequency  of  the 
sins  committed.  The  contraindications  to  a  woman's  nurs- 
ing a  baby  must  be  obeyed.  Nursing  during  pregnancy, 
or  extended  over  too  protracted  a  period,  must  be  forbid- 
den. The  latter  is,  if  possible,  more  serious  than  the 
former.  Many  a  case  of  rhachitis  or  anaemia  owes  it  origin 
to  the  baby  being  nursed  into  the  second  year.  A  baby 
whose  development  is  not  normal,  for  instance,  whose  first 
tooth  does  not  appear  at  the  regular  age  of  seven  or 
eight  months,  is  either  suffering  from  a  previous  disease 
of  it  has  insufficient  or  improper  food.  If  nursed,  there- 
fore, it  ought  to  be  weaned,  or  partially  so.  Many  a 
flabby  child  at  the  breast  will  thrive  when  weaned  at  last, 
and  good  barley  and  cow's  milk  will  make  better  muscle 
and  teeth  than  poor  mother's  milk.  An  inherited  or  in- 
heritable or  communicable  disease  on  the  part  of  the 
mother  or  wet-nurse,  such  as  consumption,  rickets,  syphilis, 
serious  nervous  diseases,  intense  anaemia  forbid  nursing. 
In  not  a  few  cases  the  individual  milk  of  mother  or  wet- 
nurse  does  not  agree  with  the  baby.  When  such  is  the 
case,  unless  the  fault  can  be  detected  and  remedied,  wean- 
ing is  required.     In  most  cases  it  is  possible  to  trace  the 

3SS 


antEmia  in  childhood 

indigestibility  and  insufficiency  of  a  mother's  milk  to  the 
absence  or  prevalence  of  a  special  constituent,  mostly 
either  sugar  or — and  mainly  so — casein.  A  'beautiful 
illustration  of  this  fact  was  but  lately  exhibited  by  a  baby 
patient  of  Dr.  A.  N.  Smith.  The  mother's  milk  was  un- 
doubtedly too  white  and  too  caseinous.  The  baby's  diges- 
tion was  faulty,  his  assimilation  quite  defective.  The  ad- 
dition of  some  farinaceous  decoction  to  each  meal  from 
his  mother's  breast — a  few  teaspoonfuls  given  before  each 
meal — remedied  the  evil  somewhat,  but  the  patient's  life 
was  finally  saved  by  nothing  but  weaning  and  exclusive 
artificial  feeding.  It  is  impossible,  however,  to  consider 
now  the  question  of  infant  food  to  any  extent.  Such 
principles  as  I  have  laid  down  in  Buck's  Hygiene,  and 
very  briefly  in  my  paper  on  infant  diarrhoea  and  dysentery, 
have  guided  me  through  the  better  part  of  my  life.  I  shall 
not,  therefore,  tire  your  patience  by  repeating  them. 
There  are,  however^  a  few  simple  words  which  I  cannot 
repeat  too  often.  Avoid  solid  food  .in  the  care  of  an  in- 
fant. Avoid  cow's  milk  either  undiluted  or  diluted  with 
water  only.  Avoid  condensed  milk  diluted  with  water 
only.  Use  no  milk  without  the  addition  of  some 
gelatinous  or  farinaceous  decoction,  barley,  oatmeal,  gum 
arable,  gelatine.  In  anaemia,  add  beef  soup  to  the  uniform 
infant  food  daily.  Give  solid  food,  that  is  a  small  piece 
of  meat,  a  crust  of  bread,  half  an  egg,  about  the  end  of 
the  first  year.  Keep  up  this  simple  diet  for  another  year, 
and  add  slowly  such  articles  of  food  as  physiology  and 
experience  permit.  Prohibit  bad  habits,  such  as  irregular 
and  fast  eating,  cold  feet  and  highland-fashion  legs,  and 
enforce  out-door  exercise;  children  before  and  after  an 
out-door  play  are  different  beings.  Avoid  crowded  school- 
rooms and  the  excess  of  private  lessons.  A  child  sleeping 
after  a  healthy  exercise  of  his  muscles  and  lungs  will 
finally,  besides  being  stronger  and  healthier,  learn  more 
than  one  who  hangs  his  pale  cheeks,  sleeping  over  his 
books.  We  have  laws  to  protect  children  from  being  sent 
to  work  in  factories,  or  to  be  employed  on  the  stage,  but 
we  have  none  to  protect  them  from  the  equally  destructive, 
incessant  schooling  in  close  rooms,  without  air  or  exercise. 

339 


DR.    JACOBI'S    WORKS 

There  are  too  many  books  bought  for  Christmas  and  too 
few  skates. 

Amongst  the  medicinal  agents  iron  has  long  been  the 
main  resort  in  anaemia  and  chlorosis.  This  was  so  even 
before  the  time  when  hemoglobin  was  isolated  and  found 
to  contain  all  the  iron  of  the  blood.  As  it  was  found  to 
benefit  the  cases  of  anaemia  and  chlorosis,  in  which  the 
red  blood  corpuscles  were  undoubtedly  diminished,  it  was 
believed  that  iron  had  the  ability  to  directly  increase  the 
number  and  the  quality  of  the  red  blood  globules.  But 
the  question  whether  it  is  really  the  iron  which  produces 
this  effect  has  not  been  answered  to  the  satisfaction  of  all, 
for  a  great  many  of  the  cases  get  well  while  no  iron  what- 
ever is  given,  and  in  consequence  of  change  of  diet  and 
the  securing  of  rest  and  a  better  general  condition.  Be- 
sides, there  are  a  number  of  cases  in  which  the  administra- 
tion of  iron  is  absolutely  unavailing.  Moreover,  there  is 
plenty  of  iron  in  almost  every  article  of  food.  Boussain 
gault  found  that  thus  eight  or  nine  centigrammes  (gr. 
iss.)  of  iron  are  daily  taken  into  the  body.  The  same 
quantity  has  been  found  by  Fleitmann  to  be  eliminated 
by  the  kidneys  and  the  intestinal  canal.  Thus,  there  cer- 
tainly are  cases  of  chlorosis  which  have  not  been  caused 
by  the  absence  of  iron ;  and  it  cannot,  therefore,  be  said 
that  the  iron,  by  supplying  this  lack  or  by  removing  this 
absence,  cures  chlorosis. 

But  it  is  still  a  question  whether  the  iron  thus  given, 
under  circumstances  which  are  entirely  abnormal,  does  not 
improve  the  chances  of  recovery  in  just  these  conditions. 
The  doses  given  would  certainly  be  too  large,  when  com- 
pared with  the  iron  contained  in  the  food  and  with  the 
amount  of  iron  present  in  the  whole  quantity  of  circulating 
blood,  three  grammes  and  no  more. 

Compared  with  this  small  quantity,  the  doses  we  are  ac- 
customed to  administer  are  certainly  large.  Speedy  elimi- 
nation, too,  takes  place,  through  which  the  whole  or  nearly 
the  total  amount  of  the  ingested  iron  is  removed.  But  it 
has  not  been  found  whether  the  iron  does  not  act  in  some 
other  way  besides  increasing  the  amount  of  the  metal  con- 
tained in  the  hemoglobin. 

340 


ANiEMIA    IN    CHILDHOOD 

After  iron  has  reached  the  stomach  it  is  decomposed  into 
an  oxide^  and  is  absorbed,  probably  in  the  form  of  an  al- 
buminate. There  can  be  no  doubt,  according  to  Dietl  and 
Heidler,  that  it  is  absorbed  in  the  stomach,  and  very  prob- 
ably the  upper  part  of  the  small  intestine  also.  It  reap- 
pears in  the  bile  and  the  pancreatic  juice.  Not  only  is  that 
the  case  after  it  has  been  introduced  into  the  stomach,  but 
it  will  also  reappear  in  the  bile  secretions  of  the  intestine 
and  pancreatic  juice,  according  to  A.  Mayer,  after  it  has 
been  injected  into  the  veins.  It  is  true  that  Quincke  was 
sometimes  unable  to  find  iron  in  the  intestinal  secretions 
after  it  had  been  injected  into  the  blood,  but  it  seems  to 
be  well  established,  according  to  the  experiments  of  Pro- 
kowski,  that  the  temperature  of  the  blood  is  elevated,  the 
pulse  accelerated,  and  the  blood  pressure  increased  after 
the  use  of  iron.  For  this  reason  it  ought  not  to  be  given 
during  the  height,  or  even  during  the  course  of  inflam- 
matory fevers.  A  number  of  its  preparations  are  cer- 
tainly vascular  excitants.  But  for  this  very  reason, 
while  it  is  contraindicated  in  inflammatory  fevers,  it  cer- 
tainly is  indicated  and  required  in  most  cases  of  septic 
fevers. 

The  preparations  most  beneficial  in  anaemia  of  children 
are,  in  my  opinion,  the  following:  the  lactate,  the  tincture 
of  the  pomate,  the  iodide,  the  pyrophosphate,  the  subcar- 
bonate,  and  the  tincture  of  the  chloride. 

The  lactate  and  the  pomate  are  very  digestible,  and  may 
be  given  whenever  the  indication  for  the  use  of  some  mild 
preparation  of  iron  is   established. 

The  syrup  of  the  iodide  has  an  advantage  over  the  other 
preparations  of  iron,  because  by  its  use  two  indications 
may  be  met — that  is,  where  the  additional  aid  of  an  ab- 
sorbent is  desired.  Therefore,  it  is  the  proper  remedy  in 
cases  of  slow  convalescence  after  inflammations  resulting 
in  exudation,  particularly  in  disease  of  the  glands  and 
the  lungs.  It  has,  moreover,  one  peculiarity  which  makes 
it  much  more  desirable  than  many  other  preparations,  and 
that  is,  it  is  easily  decomposed  in  the  stomach;  the  iodine 
is  set  free,  and  acts  as  an  anti fermentative  in  the  many 
cases  of  disturbed  gastric  digestion,  occurring  even  in  nor- 

841 


DR.    JACOBI'S    WORKS 

mal  children,  and  almost  certain  to  take  place  in  children 
whose  circulation  has  been  disturbed  or  whose  gastric  se- 
cretions are  certainly  below  their  normal  amount  in  conse- 
quence of  a  deficient  supply  of  blood. 

The  subcarbonate  of  iron  is  a  very  mild  preparation, 
easily  digested,  and  properly  combined  with  a  number  of 
drugs,  such  as  bismuth  or  bicarbonate  of  soda,  is  of  con- 
siderable value  when,  in  slow  convalescence  or  progressive 
anaemia,  this  gastric  catarrh  threatens  to  interfere  with  the 
improvement  in  the  general  condition.  The  doses  may  be 
larger  than  those  of  any  of  the  other  preparations.  A 
child  two  years  will  easily  bear  from  25  to  50  centi- 
grammes daily.  This  quantity,  combined  with  twice  or 
three  times  as  much  subcarbonate  of  bismuth,  and,  if  neces- 
sary, three  or  four  times  that  amount  of  bicarbonate  of 
soda,  is  a  very  proper  remedy  to  be  used  in  the  conditions 
alluded  to. 

The  tincture  of  the  chloride  of  iron,  when  neutral,  is  a 
preparation  which  is  also  easily  digested.  Doses  of  a 
gramme  daily,  or  more,  are  very  readily  digested,  and 
prove  beneficial.  This  can  be  easily  combined  with  the 
bitter  tinctures,  stomachics,  etc.  The  tincture  of  the  muri- 
ate of  iron  is  the  one,  amongst  the  ferruginous  prepara- 
tions, with  the  exception  of  those  partly  composed  of  ether, 
the  acetate,  for  instance,  which  must  be  regarded  as  a  vas- 
cular irritant,  and  wherever  the  action  of  the  heart  is 
lowered  and  blood  pressure  is  diminished,  it  is  the  prepara- 
tion which  will  be  found  most  beneficial. 

In  a  number  of  cases,  the  choice  among  the  several 
preparations  of  iron  is  an  indifferent  matter,  at  least,  so  it 
appears  to  be.  Still  it  has  seemed  to  me  that,  in  those 
cases  in  which  I  have  had  to  deal  with  anaemia  attended 
by  gastric  catarrh  and  digestive  incompetency  in  the  up- 
per portion  of  the  small  intestine,  the  pyrophosphate 
proved  very  satisfactory.  I  have  employed  the  compound 
hypophosphates  and  phosphates  a  great  deal,  which  com- 
bine iron,  potassa,  lime,  and  soda,  and,  although  it  is 
well  known  that  the  elimination  of  these  metals  and 
metalloids  is  almost  as  rapid  as  their  ingestion,  still  it  ap- 
pears that  the  effect  produced  by  such  combinations  is  a 

342 


ANEMIA    IN    CHILDHOOD 

very  happy  one  in  just  such  conditions  as  those  of  which 
we  have  just  spoken. 

All  these  preparations  are  of  special  value  in  chronic 
anaemia,  which  is  by  far  the  most  common  affection.  Acute 
impoverishment  of  the  blood,  such  as  that  caused  by  severe 
puerperal  hemorrhage  or  hemorrhage  from  the  bowels,  is 
fortunately  very  rare  in  infancy  and  childhood.  Therefore, 
the  opportunity  for  transfusion  of  human  blood  is  seldom 
offered,  even  to  those  who  are  most  fond  of  that  particular 
operation. 

The  doubtful  results  of  transfusion  upon  a  large  scale 
have  induced  a  modern  writer  to  make  a  number  of  small 
transfusions  by  means  of  the  hypodermic  syringe.  He 
would  withdraw  blood  from  the  vein  of  a  healthy  person 
and  introduce  it  directly  and  immediately  into  the  veins  of 
the  sick  child,  and  he  states  that  he  has  done  so  with 
favorable  results.  It  seems  to  me  that  the  plan  is  rational 
enough,  but  the  future  must  decide  whether  the  results 
will  be  as  favorable  as  they  have  been  reported,  and 
whether  there  will  not  be  grave  objections  to  what  is  de- 
scribed as  a  very  trifling  operation.  If  it  be  successful, 
it  would  certainly,  under  equal  circumstances,  have  the 
preference  over  the  slow  process  of  gastric,  or  of  rectal 
alimentation,  no  matter  whether  injections  of  defibrinated 
blood  or  other  nutrients  are  used. 

In  cases  of  chronic  anaemia  I  have  frequently  used  ar- 
senic; one  or  two  minute  doses  daily,  after  meals  and  well 
diluted  with  water,  and  with  benefit.  Of  one  thing  there 
is  no  doubt,  and  that  is  that  arsenic  does  good  in  a  pe- 
culiar torpid  condition  of  the  stomach  which  will  not  digest 
and  assimilate  in  consequence  of  the  absence  of  both  nerve 
power  and  gastric  juice.  Both  in  adults  and  in  children, 
I  have  given  it  for  the  purpose  of  improving  general  nu- 
trition, and  I  have  not  seen  in  children  what  very  fre- 
quently occurs  in  adults  when  arsenic  is  given  for  nervous 
disorders,  namely,  gastric  derangement.  With  iron,  with 
or  without  stomachics,  I  have  seen  the  appetite  improving, 
the  mucous  membrane  filling  with  blood,  and  vigor  return- 
ing under  its  restorative  influence.  Doses:  from  two  to 
five  drops  daily,  of  Fowler's  solution, 

343 


DR.    JACOBI'S    WORKS 

In  this  connection,  I  will  state  that  strychnia,  in  my 
hands,  has  proved  very  beneficial  as  an  adjuvant  to  either 
arsenic  or  iron.  To  a  child  two  years  old  a  dose  of  ^o 
of  a  grain  may  be  safely  given  daily,  and  this  dose  may 
be  continued  for  a  long  time.  Its  action  is  well  known  in 
cases  in  which  the  digestion  and  the  entire  nervous  power 
of  the  patient  are  simply  lowered,  and  a  few  weeks'  ad- 
ministration, together  with  proper  food  and  either  iron  or 
arsenic,  has  changed  the  condition  of  the  anaemic  child 
considerably. 

Phosphorus,  in  about  the  same  doses  as  strychnia,  has 
also  produced  very  happy  effects.  They  may  be  brought 
about  by  the  influence  of  phosphorus  upon  the  nervous 
system,  or  they  may  be  explained  bj^  the  effect  which  the 
remedy  produces  when  given  in  diseases  of  the  bones. 
Some  ten  years  ago,  Georg  Wegner  found  that  the  frac- 
tured bones  of  rabbits  fed  upon  minute  doses  of  phos- 
phorus, would  unite  much  more  rapidly  than  the  frac- 
tured bones  of  those  animals  which  were  left  to  themselves. 
Since  that  time  I  have  been  in  the  habit  of  giving  phos- 
phorus in  cases  of  acute  and  chronic  disease  of  the  bones 
of  an  inflammatory  character,  and  in  caries  particularly, 
and  my  impression  is  that  the  large  majority  of  cases  do 
very  much  better  when  small  doses  of  phosphorus,  say  ^50 
to  /4oo  of  a  grain  daily,  are  given,  than  when  the  dis- 
ease is  left  to  pursue  its  course  without  the  use  of  this 
remedy.  It  is  true  that  the  time  required  by  such  a 
process  as  caries  is  long  under  any  circumstances,  but  it 
has  seemed  to  me  that  even  caries  of  the  ankle  joint  and 
the  metatarsus  was  apt  to  progress  very  favorably  in  the 
course  of  a  number  of  months  when  phosphorus  was  used, 
whereas  years  were  required  in  other  cases  which  had  not 
received  the  same  treatment. 

I  do  not  know  that  it  has  been  used  extensively  in 
rhachitis,  but  it  is  not  improbable  that  the  good  effect 
which  phosphorus  produces  in  anaemia,  mostly  of  rhachi- 
ticial  children,  is  partly  due  to  the  fact  that  the  bones 
especially  show  an  increased  tendency  to  normal  develop- 
ment. 

In  many  cases  cod-liver  oil  is  very  serviceable;  I  need 

344 


ANEMIA    IN    CHILDHOOD 

not  speak  of  its  effect,  and  shall  only  say  that  frequently 
the  contraindications  to  its  use  are  overlooked.  Most 
children  do  not  bear  it  well  in  the  summer,  when  it  is 
apt  to  produce  either  gastric  catarrh  or  diarrhoea.  Some 
do  not  bear  it  at  all  at  any  season  of  the  year.  It  is  with 
cod-liver  oil  as  with  any  other  remedy,  particularly  iron, 
of  which  I  have  already  spoken.  There  are  children  who 
do  not  bear  either,  and,  therefore,  they  must  be  treated 
without  these  remedies.  At  all  events,  it  should  not  be 
forgotten,  whenever  digestion  is  impaired,  whenever  there 
is  gastric  catarrh,  that  these  cases  require  preliminary  treat- 
ment before  the  administration  of  either  cod-liver  oil  or 
iron  is  resorted  to. 


345 


TREATMENT  OF  INFLUENZA  IN  CHILDREN 

Prophylaxis. — Is  there  anything  like  a  preventive  of  in- 
fluenza? There  is,  contrary  to  Berger  (Die  Infections- 
Krankheiten,  1896),  and  others,  no  infectious  disease  of 
equal  communicability,  either  direct  or  indirect.  Under 
extraordinary  circumstances  only  is  there  a  possibility  of 
avoiding  contact.  Influenza  may  be  prevented  from  en- 
tering a  ship  coming  from  distant  ports,  or  a  ship  carry- 
ing it  may  be  quarantined  w^ith  rather  more  theoretical 
than  practical  eff"ect.  Influenza  may  be  kept  out  of  a 
monastery  or  a  prison  or  out  of  an  insane  asylum  or  bar- 
racks if  there  is  no  intercourse  with  the  rest  of  the  world. 
It  should  be  kept  out  of  a  sanitarium  for  lung  diseases 
by  strict  isolation  during  an  epidemic.  Indeed,  I  know  of 
no  infectious  disease  that  creates  a  greater  disposition  to 
tuberculosis  than  influenza.  To  close  a  school  is  unavailing, 
for  the  children  will  contract  the  disease  outside.  Ex- 
pectorated mucus  and  the  result  of  sneezing  should,  if 
possible,  be  caught  and  disinfected  or  destroyed;  tools, 
toys,  towels,  handkerchiefs,  and  linen  should  be  treated, 
i.  e.,  washed  and  disinfected  as  in  other  contagious  mala- 
dies. To  protect  the  children  of  a  household  the  patient 
should  be  isolated  on  the  upper  floor  of  the  house,  a  de- 
mand with  which  it  is  impossible  to  comply  in  the  larger 
part  of  our  population.  Nurslings,  if  their  mothers  be 
sick,  should  meet  them  for  nursing  only.  Sick  and  well 
children  should  use  disinfectant  mouth-washes.  I  think 
water  slightly  acidulated  with  hydrochloric  acid  will  do 
best.  Drinking-water  should  also  be  acidulated  in  the  same 
manner  and  may  have  the  same  favorable  result  that  is 
obtained  in  Asiatic  cholera.  The  irrigation  of  the  nose 
should  be  a  matter  of  course  in  the  well  and  in  the  sick, 
for  the  same  reasons  that  have  been  urged  by  myself  and 
very  persistently  and  forcibly  by  Dr.  C.  A.  Caille  against 

347 


DR.    JACOBI'S    WORKS 

and  during  diphtheria.  In  this  way  mucus,  which  accord- 
ing to  Ruhemann  catches  bacilli  as  in  a  net,  is  removed  and 
the  mucous  membrane  is  kept  in  a  healthy  condition.  In 
which  way  the  bacillus  enters  is  not  entirely  clear;  if  it 
invades  through  the  mucous  membrane  like  the  pathogenous 
bacilli  of  tuberculosis  or  diphtheria  or  cholera,  the  more 
normal  the  condition  of  the  mucous  membrane,  the  greater 
is  the  protection. 

Medicinal  preventives  have  been  recommended — cod- 
liver  oil  by  Ollivier;  calcium  sulphide  by  Greene;  quinine 
by  many.  Trials  with  it  made  on  regiments  of  soldiers 
under  control  in  their  barracks  were  equally  positive  or 
negative.  My  experience  with  preventives  is  very  small. 
Quinine   appeared  to  cause  headache  and  nausea. 

Treatment. — There  is  no  specific  for  influenza  like  qui- 
nine for  malaria  or  salicylic  acid  for  rheumatism.  Inno- 
cent muriate  of  ammonium,  also  carbonate  of  potassium, 
sulphocarbolate  of  sodium,  carbolic  acid,  ichthyol,  and  other 
remedies  have  been  so  recommended  without  the  expected 
success.  Thus,  rational,  hygienic  and  symptomatic  and  sus- 
taining medicinal  treatment  only  can  be  considered.  A 
purgative  dose  of  calomel  should  be  given  in  order  to  clear 
the  bowels  of  microbic  and  toxic  ingesta,  the  bowels  ap- 
pearing to  be  the  principal  point  of  attack  in  young  chil- 
dren. The  patient  should  be  kept  in  bed,  the  temperature 
of  the  room  at  70°  F.  or  more  at  first,  the  diet  should  be 
scanty  and  fluid  at  first^ — milk,  cereals,  farinacea,  water, 
lemonades,  and  broths.  The  further  development  of  the 
case  will  gradually  indicate  eggs,  and  perhaps — in  a  few 
selected  instances  only — alcohol  in  addition  to  other  medic- 
inal stimulants.  It  is  more,  however,  a  slow  convalescence 
that  requires  it  than  the  course  of  the  disease  itself.  In 
this  respect  it  appears  to  differ  somewhat  from  other  infec- 
tious diseases,  particularly  typhoid  fever  and  diphtheria. 
In  the  latter  the  doses  of  alcohol  should  be  high  from  the 
beginning. 

If  there  be  a  high  temperature,  cold  water  is  not  indi- 
cated either  as  a  bath  or  as  a  pack.  The  irritating  cough 
which  often  requires  opiates  is  rather  increased  than 
soothed  by  it;  the  characteristic  bronchitis  of  influenza  does 

348 


TREATMENT    OF    INFLUENZA   IN    CHILDREN 

not  bear  it;  the  frequent  copious  perspiration  contraindi- 
cates  it,  and  so  does  a  weak  heart  under  all  circumstances. 
On  the  contrary,  when  there  is  much  muscular  pain  and 
restlessness,  a  warm  bath  is  often  beneficial.  Hot  baths 
should  be  avoided  unless  a  very  short  one  in  an  occasional 
collapse,  and  Turkish  baths  require  stronger  heart-muscles 
than  we  are  apt  to  meet  in  pronounced  cases  of  influenza. 
While  many  common  cases  of  pneumonia,  with  fair  cir- 
culation, are  apt  to  do  well  M'ith  cold  packs,  influenza  pneu- 
monias do  better  with  warm  ones. 

According  to  Ditmar  Finkler  of  Bonn  quinine  occupies 
a  front  rank.^  Out  of  eighty  of  his  patients  treated  with 
quinine  only  three  made  their  appearance  at  the  dispensary 
a  second  time,  while  of  those  treated  with  other  drugs  nearly 
one-half  reappeared  twice  or  more  frequently.  The  fav- 
orable action  of  this  drug  has  been  observed  by  Dujardin- 
Beaumetz,  Tessier,  Carriere,  Pribram  and  others.  Mosse, 
to  abort  the  disease,  administered  1.0-1.25  grams  the  first 
day,  sometimes  also  the  second.  Filatow  has  also  observed 
its  favorable  effect  especially  in  children.  Others,  how- 
ever, as  Eichhorst,  Tranjen  and  Bowie,  had  no  success  in 
the  use  of  this  remedy,  and  Leichtenstern  believed  that  the 
cases  treated  with  large  doses  of  quinine  did  worse  than 
those  that  were  not  so  treated.  In  the  German  collective 
investigation  reports  some  praised  quinine  as  giving  bril- 
liant results,  while  others  were  greatly  disappointed  in  its 
effects. 

Whenever  vomiting  is  severe,  stomach  feeding  is  out 
of  the  question.  The  temporary  abstinence  and  afterward 
rectal  alimentation  find  their  indication.  Alcohol  greatly 
diluted,  peptones,  mild  salt  solutions,  and  liquid  albumins 
are  readily  absorbed  in  the  colon  which  even  in  the  smallest 
infant,  though  the  fetal  length  of  the  sigmoid  flexure  may 
be  persistent,  is  made  accessible  by  elevating  the  hip  and 
moderating  the  current  by  not  raising  the  irrigator  more 
than  a  foot  above  the  anus.  Peptonized  milk,  egg  and 
broths  are  absorbed  in  part.  Starch  in  the  injection  is 
dextrinized  in  the  colon  and  thus  adds  to  the  nourishment 

1  Finkler.    "  Twentieth  Century  Practice  of  Medicine,"  Vol.  XV. 

3i9 


DR.    JACOBI'S    WORKS 

of  the  enema,  but  though  water  alon**  were  injected  it  would 
add  to  the  circulating  fluid.  Thai  *<  why  even  a  large 
enema  given  for  the  purpose  of  clearing  the  bowels  may 
add  to  nutrition  and  strength  by  such  of  the  injected  water 
as  is  almost  invariably  retained.  Thus,  severe  vomiting 
should  be  treated  with  refusing  to  feed  through  the  stom- 
ach. The  best  relief  is  given  by  morphine,  rarely  by  ice, 
either  internally  or  externally.  It  is  not  necessary  to  send 
morphine  down  to  the  stomach ;  absorption  is  easy  and  more 
readily  accomplished  in  the  mouth  or  throat.  A  tablet  of 
one  milligram  may  be  thrown  into  the  mouth  of  a  child 
of  two  or  four  years,  there  to  be  absorbed,  or  half  a  drop 
or  one  drop  of  Magendie's  solution  may  be  administered  in 
the  same  manner  without  dilution. 

The  indications  for  the  treatment  of  influenza  may  be 
several,  the  high  temperature  in  manj^  cases,  the  great  dis- 
comfort, the  restlessness,  and  the  rapidly  increasing  ex- 
haustion. In  the  treatment  of  many  fevers  it  is  their  causes 
that  require  consideration;-  in  others,  however,  their  rela- 
tions to,  and  influence  on,  the  body  are  the  main  considera- 
tions. When  the  condition  of  the  latter  is  fair,  and  no 
danger  is  incurred  on  account  of  the  fever,  it  should  be 
left  alone;  when  the  rise  of  temperature,  however,  by  itself 
is  injurious,  it  should  be  interfered  with.  At  all  events 
the  treatment  of  the  symptom  "  fever  "  gives  us  no  hope 
of  shortening  the  disease  in  which  it  occurs  or  of  which 
it  forms  a  part;  on  the  other  hand,  it  is  a  satisfaction  to 
know  that,  while  we  increase  the  comfort  and  diminish  the 
immediate  dangers,  the  natural  healing  process  is  not  dis- 
turbed. In  this  way  both  the  justification  and  the  limita- 
tion of  the  so-called  expectant  treatment  become  evident. 
To  allow  a  high  temperature  to  deteriorate  tissues  and  ex- 
haust the  heart  or  brain,  is  as  injudicious  as  is  the  custom 
of  emphasizing  the  number  of  degrees  of  Fahrenheit  as  the 
only  valuable  part  of  a  morbid  process.  To  be  satisfied 
with  depressing  temperature  is  a  grave  mistake,  but  to 
allow  pneumonia  to  run  its  deleterious  course  of  high  tem- 

2  Jacobi,  A.  Fevers  and  Fever  Remedies,  Albany  Medical 
Annals,  May,   1900. 

350 


TREATMENT    OF    INFLUENZA    IN    CHILDREN 

peratures  unchecked  with  their  full  influence  on  the  rapid- 
ity of  respiration  and  the  action  of  the  heart  and  on  the 
increase  of  waste,  is   equally  injudicious. 

In  their  injurious  influence  on  nutrition  protracted  in- 
fectious fevers  act,  first,  like  direct  losses  or  like  starvation, 
and,  secondly,  as  immediate  poisons.  The  younger  the  pa- 
tient, the  greater  is  the  danger  from  that  source.  That 
is  why  a  high  temperature  without  any  or  with  a  trifling 
remission  should  not  be  allowed  to  last,  though  its  imme- 
diate eff'ect  may  not  appear  very  ominous.  When  a  high 
temperature  results  in  a  convulsion  we  never  hesitate  to 
reduce  it;  here  we  admit  there  is  a  vital  indication.  Why, 
then,  not  reduce  it  while  there  is  the  danger  of  a  possibility 
or  probability  of  its  occurrence?  Add  to  these  facts  the 
disposition  of  the  j^oung  to  inanition  which  is  caused  by  two 
main  factors.  The  first  is  their  rapid  metabolism,  the  sec- 
ond and  principal  one  is  the  relative,  almost  universal, 
insufficiency  of  the  young  organism. 

Moreover,  we  should  not  forget  that  most  of  our  antipy- 
retics are  at  the  same  time  nervines,  analgesics  and  dia- 
phoretics, thus  improving  comfort  and  metabolism.  They 
are  surely  indicated  when  bathing  is  not  sufficiently  effi- 
cient or  when  baths  are  contraindicated ;  in  that  case  they 
may  act  as  adjuvants,  as  combinations,  and  procure  sleep 
and  remissions.  If  I  add  that  there  are,  however,  contra- 
indications to  the  use  of  medicinal  antipyretics  because  of 
possible  idiosyncrasies  and  of  the  debilitating  eff"ects  which 
many  of  the  antipyretic  drugs  are  apt  to  exhibit,  I  merely 
say  what  all  have  experienced,  and  what  everybody  should 
remember,  viz.,  that  no  degree  of  Fahrenheit  and  no  Greek 
name  of  a  morbid  process  are  the  subjects  of  our  medi- 
cation, but  an  individual  patient.  From  these  points  of 
view  our  fever  remedies  should  be  judged. 

In  my  paper  of  1890^  I  said  that  acetanilid  ought  to 
be  preferred  among  the  poor  because  of  its  low  price,  anti- 
pyrin  mainly  where  great  solubility  was  required  for  the 
purpose  of  its  administration  in  rectal  and  subcutaneous 
injections,   and  that  phenacetin  was  preferable  to  either 

3  Jacobi,  New  York  Medical  Record,  1890. 
351 


DR.    JACOBI'S    WORKS 

when  it  could  be  given  by  the  mouthy  because  of  its  less 
uncomfortable  effect  on  the  brain,  the  heart,  and  the  skin. 

This  opinion  I  have  to  modify  to  a  certain  extent,  not 
that  I  object  to  what  I  said  of  phenacetin,  but  acetanilid 
should  never  have  an  opportunity  to  show  what  good  quali- 
ties it  may  have,  in  the  rich  or  poor.  It  should  not  be  used 
at  all,  under  any  circumstances,  not  even  in  the  quack 
preparations  which  now  and  then  I  know  to  disfigure  the 
prescriptions  of  regular  practitioners.  Being  a  derivative 
of  anilin,  acetanilid  is  poisonous.  Not  only  has  it  a  seda- 
tive or  rather  paralyzing  effect  on  the  central  nervous  sys- 
tem, but  it  destroys  the  blood  and  causes  anemia  by  chang- 
ing hematin  into  methemoglobin,  though  given  sometimes 
in  small  doses.  That  is  what  gives  rise  to  cyanosis  so  often 
observed,  more  often  than  after  the  administration  of  any 
other  of  our  modern  analgesics  and  antifebriles.  ,The  poi- 
sonous effect  is  even  noticed  when  the  drug  is  used  exter- 
nally, mainly  on  the  young.  Examples  of  such  cases  were 
reported  at  the  meeting  of  the  Philadelphia  Pediatric  So- 
ciety, April  11,  1899. 

Antipyrin,  when  employed  during  normal  conditions,  in- 
creases the  tension  of  the  pulse  and  blood  pressure — there- 
fore it  is  contraindicated  in  hemoptysis — and  produces  per- 
spiration. It  works  more  on  the  general  central  nervous 
system  than  on  the  center  of  circulation,  that  is  why  it 
acts — while  being  antipyretic — as  a  sedative  and  analgesic. 
But  it  should  not  be  considered  as  a  nervine,  for  its  action 
appears  to  be  ushered  in  through  the  mediation  of  the  blood 
and  blood-vessels.  The  body  temperature  begins  to  de- 
crease within  fifteen  or  twenty  minutes  after  the  first  dose; 
to  render  its  antipyretic  effect  more  tangible  and  persistent, 
it  should  be  followed  by  a  second  within  two  hours.  This 
rule,  however,  does  not  hold  good  when  the  drug  is  given 
for  its  sedative  or  analgesic  or  for  its  slight  anti-rheumatic 
effect.  Its  general  effect  is  mostly  good,  but  its  undesir- 
able effects  are  many.  Otto  Seifert  *  quotes  eighty  authors 
of  note  who  report  disagreeable  effects  of  antipyrin;  they 

4  Seifert,  Otto.  Wtirzburger  Abhandlungen  aus  dem  Gesammt- 
gebiet  der  prakt.  Med.,  1900. 

B52 


TREATMENT    OF    INFLUENZA    IN    CHILDREN 

were  observed  in  the  gastro-intestinal,  nervous  and  circu- 
latory sj^stem,  in  the  skin  and  in  the  mucous  membranes. 
Phenacetin  is  dismissed  with  ten.  It  resembles  acetanilid, 
but  is  very  much  milder  in  its  effect.  The  transformation 
into  methemoglobin  takes  place  after  large  doses  of  several 
grams  only.  Half-gram  doses  for  antipyretic,  gram  doses 
for  analgesic  purposes  are  recommended.  The  doses  to  be 
given  to  infants  and  children  should  be  from  fifteen  milli- 
grams to  three  centigrams  (gr.  4-2)- 

Salipyrin,  the  salicylate  of  antipyrin,  is  employed  by 
Finkler.  While  antipyrin  causes  perspiration,  sometimes 
excessively  so,  he  reports  a  case  in  which  hyperidrosis  was 
instantly  cured  by  salipyrin.  It  should  be  given  in  twice 
the  doses  of  antipyrin,  is  usually  better  tolerated  than  the 
latter,  particularly  by  neurotic  or  neuralgic  patients,  be- 
cause of  the  relative  absence  of  accidental  effects. 

Salophen  is  extolled  by  Drewes  of  Hamburg,  who  pre- 
fers it  to  salicylic  acid  and  to  salicylate  of  sodium,  mainly 
in  the  nervous  form  of  influenza.  Adults  took  from  one 
to  six  grams,  children  from  three  to  five  decigrams.  Fink- 
ler, who  quotes  him,  adds:  "  I  believe  that  most  physicians 
have  arrived  at  the  point  where  they  would  not  like  to  be 
without  these  preparations  in  influenza,  but  it  should  cer- 
tainly not  be  forgotten  that  reports  of  this  kind  have  quite 
frequently  been  used  for  advertising  purposes." 

There  is  something  else  that  should  not  be  forgotten, 
viz.,  that  there  is  hardly  a  disease  which  has  as  great  a 
tendency  to  cause  exhaustion  and  numerous  other  nervous 
symptoms,  from  languor  to  heart  failure,  as  influenza.  If 
there  be  the  slightest  indication  of  such  a  danger,  none  of 
the  above-mentioned  drugs  should  be  given  without  the  ad- 
dition of  a  stimulant.  That  should,  according  to  what  I 
said  before,  rarely  be  alcoholic.  Caffein  preparations  are 
vastly  preferable;  mainly  the  salicylate  (or  benzoate)  of 
sodio-caffein,  which  being  verj^^  soluble  and  readily  ab- 
sorbed, is  almost  ideal  in  its  effect.  That  is  why  in  emer- 
gency cases  of  heart  failure  its  subcutaneous  administra- 
tion may  often  become  indispensable.  The  use  of  strych- 
nine is  so  well  understood  and  so  general  that  I  limit  my- 
self to  merely  mentioning  it. 

353 


DR.    JACOBI'S    WORKS 

To  what  extent  stimulants  should  be  given  in  the  aver- 
age or  in  the  grave  cases  depends  on  the  general  condition 
of  the  patient,  and  on  his  medical  adviser's  knowledge  of 
his  former  health  and  his  resisting  power.  It  is  probable 
that  in  most  cases  some  daily  doses  of  sulphate  of  spartein, 
five  centigrams  (gr.  5 /Q')  for  a  child  of  two  years,  will  have 
a  favorable  effect.  The  caffein  preparation  I  mentioned 
may  be  given  in  doses  of  from  two  to  six  decigrams  (grs. 
iij-x)  daily.  When  it  appears  to  act  as  an  excitant  on  the 
brain,  it  should  be  replaced  by  camphor  in  daily  doses  of 
from  one  to  four  decigrams.  All  these  doses,  however, 
should  be  much  increased  when  strong  stimulation  is  re- 
quired, and  in  an  emergency  subcutaneous  injections  of 
the  same  drugs  should  be  used,  caffein  being  soluble  in  two 
parts  of  water  and  camphor  in  four  parts  of  sweet  almond 
oil. 

One  of  the  best  stimulants,  useful  in  the  gravest  of  all 
cases  which  are  attended  with  collapse  and  heart  failure, 
is  sadly  overlooked  among  us,  viz.,  Siberian  musk.  I  know 
of  nothing  better  in  the  most  urgent  of  cases.  A  child 
of  two  years  should  take  of  the  10  per  cent,  tincture  five 
to  ten  minims  every  half  hour  until  half  a  dozen  or  a 
dozen  doses  have  been  taken.  Musk,  together  with  large, 
hot  enemata,  has  led  me  over  many  a  difficult  pass,  and  I 
again  offer  this  experience  of  mine,  which  now  extends 
over  fifty  years,  as  a  contribution  to  your  aid  in  dire  dis- 
tress, always,  however,  reminding  you  of  the  fact  that  all 
these  measures  are  not  exclusive  to  influenza,  but  to  all 
conditions  of  nerve  exhaustion,  no  matter  from  what  cause. 

At  last,  let  me  allude  to  a  singular  experience  which 
was  published  ten  years  ago.  I  do  not  know  that  it  has 
been  repeated  since."^  Goldschmidt  ®  reports  as  follows : 
"  About  New  Year's,  1890,  a  lady  suffering  from  influenza 
landed  in  Madeira  and  disseminated  the  disease  in  a  short 
time.     Two  months  previously  there  had  been  an  epidemic 

5  In  the  discussion  following  the  reading  of  this  paper  Dr. 
Holbrook  Curtis  referred  to  the  internal  use  of  vaccine  virus  by 
himself   and   others.     A.   J. 

6  Goldschmidt.  Immunity  Through  Vaccination,  Berl.  klin. 
Woch.,  1890  and  1891. 

354 


TREATMENT    OF    INFLUENZA   IN    CHILDREN 

of  smallpox  and  numerous  vaccinations  and  revaccinations 
were  performed.  Now,  it  so  happened  that  all  those  who 
were  successfully  vaccinated — 112  all  told — remained  free 
of  influenza.  Of  98  who  were  vaccinated  unsuccessfully, 
only  15  took  sick."  The  author  concludes  from  this  ex- 
perience that  successful  vaccination  is  a  preventive  against 
influenza.  But  as  yet  there  is  not  enough  known  to  justify 
any  such  conclusion  with  anything  like  certainty.  Still, 
it  suggests  the  possibility  of  a  future  serotherapy  for  in- 
fluenza and  its  very  serious  consequences. 


355 


OTITIS   MEDIA  IN   CHILDREN 

Dr.  G.  Heermann  published  in  1898  a  small  book  on 
"Otitis  Media  in  Infancy  (Otitis  Concomitans)."  For  a 
part  of  the  critical  history  of  that  affection  I  refer  you 
to  him.  When  I  looked  over  the  shelves  of  our  library 
which  are  filled  with  books  and  phamphlets  written  on  the 
ear,  and  glanced  over  the  literature  contained  in  the  sub- 
ject catalogue  of  the  Surgeon-General's  Library,  I  was 
glad  to  remember  that  I  must  not  take  more  than  fifteert 
minutes  of  your  time.  This,  then,  is  not  an  historical 
paper. 

Otitis  media  is  of  frequent  occurrence  in  the  very  young. 
It  may  combine  with  the  retrograde  involution  of  the  em- 
bryonal myxomatous  tissue,  which  may  disappear  soon  after 
birth  but  persists  often  in  the  antrum  and  tympanic  cavity 
and  undergoes  purulent  softening.  Otitis  media  may  ex- 
hibit mild  and  grave  symptoms,  like  every  form  of  inflam- 
mation in  other  organs.  For  instance,  the  localized  mild 
croupous  or  lobular  pneumonia,  and  one  that  migrates  or 
terminates  in  induration  or  in  atelectasis  or  abscess,  is  still 
called  a  pneumonia  and  nothing  else.  Otitis  may  be  either 
a  mere  surface  affection  of  the  mucous  membrane,  or  one 
complicated  or  not  with  thrombosis,  or  suppuration,  or 
caries,  or  facial  paralysis,  or  meningeal  or  other  complica- 
tions, and  is  still  denominated  an  otitis.  It  may  be  either 
primary  or  secondary  to  a  naso-pharyngeal  disease,  or 
cause  or  be  caused  by,  or  appear  contemporaneously  with, 
pneumonia,  meningitis,  or  enteritis ; — it  is  still  an  otitis. 
That  is  why  I  decline  to  subdivide  otitis  as  Heermann  has 
done — into  a  bona-fide  otitis  and  a  concomitant  otitis,  the 
latter  name  being  given  to  those  forms  which  are  observed 
in  atrophic  or  emaciated  infants,  whose  general  illness, 
however,  shows  no  actual  differences  in  the  symptoms  or 
even  in  the  course  of  their  local  disease,  or  in  their  bacteri- 

357 


DR.    JACOBI'S    WORKS 

ology.  What  we  have  to  remember  is  the  fact  that  the  same 
symptoms  and  extent  of  local  changes  do  not  belong  to 
all  cases  equally,  and  that  the  same  therapy  is  not  adapted 
to   every  case. 

Purulent  otitis  is  frequently  found  in  autopsies.  Prey- 
sing  found  in  those  made  on  100  infants  that  died  of  a 
variety  of  diseases,   81    affected   with  otitis   media.     Only 

8  were  unilateral,  so  that  there  were  154  diseased  ears  among 
100  dead  infants.  Nor  are  older  children  exempt.  Gep- 
pert  found  a  latent  otitis  media  in  75^  of  all  the  inmates 
of  the  children's  hospitals  he  examined.  These  are  the 
same  results  which  are  obtained  by  previous  and  succeeding 
observers  of  the  same  disease  when  occurring  at  different 
ages.  School-children  have  been  examined  in  that  direc- 
tion a  great  many  times,  but  I  give  only  two  instances 
which,  so  far  as  I  know,  have  not  been  copied  in  our 
journals.  Dillner  found  among  38  children  that  had  to 
be  excluded  from  their  schools  on  account  of  incompetence 

9  still  suffering  from  inflammatory  ear  diseases;  Kalischer, 
among  255  children  excluded  because  they  made  no  prog- 
ress and  hindered  their  class-mates,  80  with  previous  or 
still   persistent   middle-ear   inflammmations. 

Pyogenous  microbes  enter  the  middle  ear  mainly  from 
the  naso-pharynx,  which,  according  to  R.  O.  Neumann,^ 
contains  even  in  its  normal  condition  a  large  number  of  mi- 
crobes, mainly  micrococcus  pyogenes  albus  in  from  86  to 
90^  and  the  bacillus  pseudo-diphtheriae  in  98^  of  all 
cases.  In  nasal  catarrh  there  is  a  relative  increase  of 
the  bacillus  pneumoniae  of  Fraenkel  and  Friedlander,  of 
streptococcus  pyogenes,  and  of  the  bacillus  of  diphtheria. 
These  latter  may  cause  nasal  catarrh,  while  the  bacillus 
pseudo-diphtheriae  is  a  saprophyte  only.  Thus  my  fre- 
quent statement  that  many  cases  of  nasal  catarrh  during 
an  epidemic  of  diphtheria  were  diphtheritic — first  based  on 
clinical  observations  published  in  the  American  Medical 
Times,  of  August,  I860, — is  confirmed  by  the  most  recent 
bacteriologic  research.^ 

i"Zeitschr.  f.  Hyg.  und  Inf.  Krkh.,"  1902,  vol.  40. 

2  "  Therapeutics  of  Infancy  and  Childhood,"  3d  edition,  p.  407. 

358 


OTITIS    MEDIA   IN    CHILDHEN 

Microbes  get  into  the  middle  ear  in  the  contiguity  of  the 
surface  of  the  mucous  membrane  progressively,  not  neces- 
sarily in  every  case  of  diphtheria,  scarlatina,  or  other  erup- 
tive disease,  but  still  frequently;  or  they  are  thrown  in 
during  coughing,  vomiting,  or  sneezing.  That  is  mainly 
so  when  the  nares  are  obstructed  by  catarrhal  swelling,  or 
by  the  presence  of  mucus  or  of  a  membrane,  or  by  a  high 
degree  of  congerrital  deviation.  Nurslings  are  in  danger 
during  suckling  and  deglutition — the  more  so  the  lower  their 
vitality  and  the  more  fragile  their  epithelia,  the  feebler 
their  circulation  and  the  greater  their  emaciation.  It  is  in 
these  conditions  that  microbes,  mainly  cocci,  which  are  ubiq- 
uitous in  the  accessible  cavities,  will  enter  the  tube  with 
great  facility  and  meet  those  which  are  previously  in- 
habiting it,  and  which  become  very  effective  by  the  cir- 
cumstance that  under  the  influence  of  ill  nutrition,  atrophy, 
and  colds,  the  vibrating  epithelia  become  paralyzed.  This 
latter  condition  is  easily  produced,  on  account  of  the  nor- 
mally slow  air  current  in  the  Eustachian  tubes  and  in  the 
middle  ear.  A  very  direct  cause  of  otitis  media  is  found  in 
the  presence  of  naso-pharyngeal  diphtheria  or  straightfor- 
ward "  nasal  "  diphtheria,  which  in  its  mild  or  grave  form 
is  by  no  means  so  uncommon  as  a  very  modern  author  seems 
to  believe,  who  thinks  it  worth  while  to  publish,  in  three 
long  articles,  three  new  cases  of  primary  nasal  diphtheria. 
It  is  true  that  in  this  paper  there  is  a  display  of  such  erudi- 
tion as  is  apt  to  be  exhibited  in  quotations.  The  author's 
literature  goes  back  to  antiquity,  and  that  antiquity  to  1900, 
aye  to  1890.  I  admit  that  is  uncommon  research  in  our 
over-productive  journal  literature.  But  there  is  still  more 
ancient  literature  on  the  subject.^  In  nasal  and  naso- 
pharyngeal diphtheria,  otitis  media  is  quite  frequent,  per- 
haps, however,  not  quite  so  frequent  as  we  might  expect  if 

3  The  contributions  to  diphtheria,  published  in  the  Journal 
of  Obstetrics,  February,  1875;  the  article  on  "Diphtheria,"  in 
the  second  volume  of  Gerhardt's  Handbook,  1877;  and  the 
Treaties  on  Diphtheria,  published  by  Wm.  Wood  &  Co.,  1880; 
even  the  several  editions  of  the  Therapeutics  of  Infancy  and 
Childhood — all  of  which  references  are  in  our  own  library — 
contain   what   would   have    facilitated   modern   rediscoveries. 

S5Q 


DR.    JACOBI'S    WORKS 

we  overlooked  the  cases  in  which  the  membrane  is  solid  and 
firmly  closes  the  orifice  of  the  Eustachian  tube.  It  is  mostly 
observed  in  those  cases  of  nasal  diphtheria  in  which  the 
membranous  deposits  are  very  light  and  flocculent  and 
the  secretions  copious  and  acrid.  It  is  principally  this 
class  of  cases  in  which  the  nasal  injections  or  irrigations 
introduced  by  me  more  than  forty  years  ago  prove  life- 
saving,  and,  as  to  ears,  preventive. 

In  diphtheria  of  the  throat,  a  slight  swelling  of  the  mu- 
cous membrane  or,  as  I  have  said,  a  moderate  diphtheritic 
deposit  may  close  the  Eustachian  tubes,  and  hard-hearing 
may  be  the  result.  In  this  class  of  cases  the  patient  com- 
plains not  infrequently  of  intense  pain  behind  the  angle 
of  the  jaw  and  in  the  ear,  and  in  some  cases  the  diphther- 
itic membrane  is  continued  into  the  tubes,  and  gives  rise  to 
otitis  interna  and  media,  which  finally  terminates  in  per- 
foration of  the  drum  membrane,  and  occasionally  in  caries 
of  the  bones.  Wreder  *  collected  1 8  cases  of  diphtheria 
of  the  middle  ear  in  scarlatina,  complicated  with  the  same 
affection  of  the  fauces  and  nares.  One  child  with  diph- 
theria of  the  mouth  and  pharynx  had  also  diphtheria  of 
the  inner  ear.  Kuepper  saw  diphtheria  of  the  middle  ear 
and  Eustachian  tube,  and  Wendt  once  in  the  tubes,  and, 
amongst  84  cases  of  variola,  twice  in  the  middle  ear,  to- 
gether with  the  same  affection  in  the  naso-pharyngeal  cav- 
ity." 

A  frequent  cause  of  otitis  media  is  scarlet-fever,  with 
its  coccic  or  bacillary  throat  affection.  In  mild  or  severe 
cases  there  may  be  perforation  of  the  drum  membrane, 
necrosis  of  the  drum  membrane  and  of  bones,  progress  of 
that  process  to  the  antrum  and  the  cells  of  the  mastoid 
processes  and  to  the  sinuses  and  meninges,  with  the  results 
of  pyaemia,  brain  abscess,  or  septicaemia.  In  some  of 
these  cases  of  scarlatinal  otitis  media  there  may  be,  without 
many  apparent  local  symptoms,  fever,  delirium,  diarrhoea, 
or  bronchitis.  Many  such  cases  while  yielding  no  pairt 
from  pressure   on  the  mastoid  process   exhibit    fever,   not 

4  Monatschr.  f.  Ohrenh.,  x.,  1868. 

5  Quoted  from  my  Treatise  on  Diphtheria,  1880. 

360 


OTITIS    MEDIA    IN    CHILDREN 

always  with  a  steep  pyaemie  curve,  and  merely  a  swelled 
lymph  node  on  the  mastoid  process.  In  that  condition  it 
is  safer  to  take  these  seemingly  mild  cases  seriously,  and 
to  operate.     Pus  may  be,  and  frequently  is,  inside  the  bone. 

In  measles,  influenza,  typhoid  fever,  and  variola  otitis 
media  is  not  quite  so  frequent  as  in  scarlatina.  Otherwise, 
all  the  varieties  of  nasal,  pharyngeal,  and  naso-pharyngeal 
catarrh,  also  adenoid  vegetations  and  hypertrophied  tonsils, 
are  known  to  be  frequent  causes  or  accompaniments  of  ear 
disease.  The  influence  of  hypertrophied  tonsils  is  perhaps 
exaggerated  in  the  estimation  of  many  of  us  in  this,  that 
when  uncomplicated  they  do  not  easily  cause  otitis;  but  it 
is  true  that  there  are  but  a  few  cases  in  which  they  stand 
alone,  by  themselves.  They  are  almost  always  complicated 
with  catarrh  in  the  neighborhood,  and  with  accumulations  of 
mucus  which  cannot  be  readily  dislodged  and  undergo  dis- 
integration. To  that  fact  Yeardsley  drew  attention  seventy 
years  ago.  Altogether,  to  my  certain  conviction,  the  role 
of  the  tonsils  in  other  conditions  is  also  over-estimated. 
I  may  be  permitted  to  mention  here,  as  I  have  done  many 
times  before,  that  their  influence  in  admitting  cocci,  bacilli, 
and  toxins  as  a  cause  of  scarlatina,  diphtheria,  tuberculo- 
sis, and  rheumatism  is  inferior  to  the  absorbing  power  of 
the  numerous  surrounding  lymph  bodies,  for  these  latter 
are  in  a  much  more  intimate  connection  with  the  lymph 
circulation  than  the  tonsils  which  are  surrounded  by  a 
firm  capsule.  Some  of  the  causes  which  carry  noxious 
material  into  the  tube  I  have  mentioned.  I  emphasize 
again  the  influence  of  coughing — mainly  in  whooping- 
cough,  but  also  in  pneumonia — of  vomiting,  and  of  sneez- 
ing, also  possibly  of  medicinal  and  other  injections  into 
the  nares ;  of  a  transfer  by  the  fingers  of  enteritic  material, 
particularly  when  the  Eustachian  tube  is  made  more  ac- 
cessible by  a  bifid  uvula,  or  when  the  soft  or  hard  palate 
is  fissured,  or  in  the  presence  of  impeding  adenoids;  for 
then  the  levatores  palati  muscles  have  no  support  and  the 
muscles  of  the  tubes  are  insufficient  and  atrophied. 

Primary  tuberculosis  of  the  middle  ear  is  rare.  It  may 
be  the  result  of  bacilli  entering  from  outside  through  the 
perforated    drum    membrane,    or   through    the    Eustachian 

361 


DR.    JACOBINS    WORKS 

tube  during  coughing  or  sneezing.  Secondarily'',  it  de- 
pends on  invasion  through  the  Eustachian  tube  in  cases  of 
pharyngeal,  laryngeal,  or  pulmonary  tuberculosis,  or  through 
the  circulation.  This  happens  mostly  during  the  gland- 
ular and  bone  tuberculosis  of  the  young,  and  in  miliary 
tuberculosis.  Altogether  the  reports  differ  in  regard  to 
the  frequency  of  tuberculosis  otitis  media.  Bezold  found 
only  127  cases  amongst  17>087  ear  patients.  Amongst  the 
chronic  abscesses  of  the  middle  ear  4.4^  are  tuberculous. 
Few  of  them  occur  in  infants  and  children,  that  is  only  5.5^ 
of  the  whole  number,  while  the  remaining  9'i>-5^  belong 
to  advanced  age  (Habermann).  Abscesses  of  the  internal 
ear  though  they  be  in  tuberculous  children  need  not  re- 
sult from  or  contain  tubercle  bacilli,  though  according 
to  one  statistical  report  9^  of  all  the  abscesses  were  said 
to  have  been  found  in  tuberculous  children,  and  a  few  of 
them  had  miliary  tuberculosis.  The  otitis  media  depended 
in  almost  every  case  on  pneumococci. 

In  cerebro-spinal  meningitis  the  ear  is  often  affected, 
more,  it  appears,  in  some  epidemics  like  that  of  this  year 
(1894)  than  in  others,  I  never  saw  a  case  of  deafness  and 
consecutive  deafmutism  originating  in  cerebro-spinal 
meningitis  that  recovered.  Whether  preventive  measures 
may  reduce  this  untoward  experience  remains  to  be  seen. 
For  nasal  affections  are  frequent.  In  almost  every  case 
of  mine,  observed  this  year,  there  was  catarrh;  in  all  that 
were  examined  for  it,  diplococci  meningo-intercellulares 
were  found  in  large  numbers.  This:  nasal  affection  may 
and  does  lead  to  otitis  media.  The  labyrintji  deafness 
occurring  during  the  height  of  the  disease  has  thus  far 
proved  very  unfavorable. 

Inflammations  of  the  inner  ear  are  rare,  only  two  in 
Preysing's  197  cases.  Perhaps  the  majority  depend  on 
cerebro-spinal  meningitis.  In  one  of  these  cases  the  trans- 
mission was  not  even  direct,  for  the  first  result  of  the 
otitis  media  was  a  purulent  meningitis,  in  the  course  of 
which  the  inner  ear  of  the  opposite  side  became  diseased. 
Meniere's  symptoms,  namely,  disturbance  of  the  equilibrium, 
nausea,  and  vomiting,  are  not  often  observed.  They  will 
always  get  worse  after  quinine  or  salicylic  acid. 

362 


OTITIS    MEDIA   IN    CHILDHEN 

The  contents  of  the  middle  ear  may  be  visible  through 
the  drvun  membrane  or  not;  the  latter  may  bulge  or  not. 
That  is  why  in  very  many  cases  otitis  media  may  not  be 
accessible  to  a  diagnosis,  and  perforation  of  the  drum  mem- 
brane is  not  so  common  as  might  be  expected.  It  happened 
in  only  nine  of  Preysing's  154  diseased  ears.  This  infre- 
quency  of  perforations  is  believed  to  be  due  to  several 
reasons. 

1.  The  greater  resistance  of  the  drum  membrane  in  the 
young,  the  external  cutis  layer  being  often  thicker  than  in 
the  adult,  the  median  connective-tissue  membrane  very  solid, 
and  the  inner  mucous  membrane  with  its  pavement  epithe- 
lium at  least  as  normal  as  in  advanced  age. 

.2.  In  the  young  the  Eustachian  tube  is  short  but  wider, 
both  at  the  isthmus  and  at  the  tympanic  orifice,  and  the 
direction  of  the  canal  almost  horizontal.  In  the  fcEtus  the 
opening  of  the  tube  is  below  the  level  of  the  hard  palate; 
at  birth  it  reaches  that  level;  in  a  child  four  years  old  it  is 
about  Sinm  above  it.''  That  is  why  Preysing  denies  the 
easy  exit  of  the  pus  into  the  pharynx.  He  claims,  what  is 
true,  that  the  pus  is  mostly  thick,  and  that  pus  would 
rather,  while  the  baby  is  on  its  back,  run  into  the  mastoid 
antrum  than  through  the  tube.  But  the  recumbent  posi- 
tion is  not  always  kept  up,  so  long  as  the  baby  is  not  yet 
on  the  autopsy  table.  Bedside  and  nursery  observers  will 
appreciate  this,  and  pathologists  might. 

It  should  be  remembered  that  most  of  the  figures  quoted 
are  taken  from  poorly  developed,  emaciated,  even  atrophic 
hospital  cases.  Now,  atrophy  affects  the  mucous  membrane 
of  the  Eustachian  tube  as  well  as  the  rest  of  the  body 
and  adds  to  the  width  of  the  tube,  which  is  thus  wider  in 
this  class  of  patients  than  in  the  healthy  and  well-nourished. 
In  this  latter,  perforation  of  the  drum  membrane  is  not  so 
very  rare,  though  indeed  many  a  case  of  otitis  media  in  this 
very  class  of  patients,  after  fever,  sensitiveness  on  pressure, 
and  meninge'al  symptoms  have  been  distinctly  noticed,  will 
run  a  mild  course  without  perforation.  Whatever  pus  does 
not  find  its  way  into  the  pharynx — no  perforation  having 

6  T.  Mark  Hovell,  2d  edition,  1901. 
363 


DR.    JACOBI'S    WORKS 

occurred — is,  or  may  be^  absorbed,  while  the  inner  mucous 
membrane,  including  that  which  covers  the  drum  membrane, 
will  become  thickened  and  give  rise  to  hard-hearing  or  even 
deafmutism.  Still  there  is  another  possibilty,  and  indeed 
one  of  frequent  occurrence.  The  copious  net  of  lymph  ves- 
sels in  the  young  is  always  very  active,  in  the  emaciate  and 
atrophic  very  greedy,  and  the  absence  (caused  by  the  dis- 
ease) of  the  pavement  epithelium  of  the  drum  membrane 
and  of  the  cylindrical  and  vibrating  of  the  interior  permits 
more  rapid  absorption.  This  condition  is  a  sufficient  ex- 
planation of  the  readiness  with  which  absorption  may  take 
place  from  the  interior  of  the  ear  into  the  lymph  and  blood 
circulation,  and  lead  to  deposits  in  distant  organs,  to  mild 
or  serious  sepsis,  to  persistent  exhibitions  of  temperature 
with  no  tangible  cause,  to  death,  or  to  slow  recovery.  More- 
over, Preysing  found  on  the  inflamed  surface,  as  the  re- 
sult of  copious  leucocyte  migration,  granulation  globules 
with  minute  blood-vessels,  without  epithelia,  resembling  in 
shape  small  tubercles,  and  surrounded  by  slight  hemor- 
rhages and  a  narrow  ring  of  beginning  organization. 
These  little  granulomata,  with  their  small  blood-vessels, 
may  also  favor  absorption. 

The  pneumococcus  which  is  found  in  otitis  is  rather 
ubiquitous.  As  we  find  it  in  pneumonia,  meningitis,  peri- 
carditis, peritonitis,  and  so  on,  we  need  not  be  surprised  at 
meeting  it  in  connection  with  the  otitis  of  the  young,  with  a 
pneumonia,  or  with  an  enteritis,  and  their  result.  Paeda- 
trophy  and  otitis  have  been  known  to  combine,  more  than 
half  a  century.  I  was  taught  their  clinical  cotemporaneous- 
ness  when  a  younger  student  of  medicine  than  I  am  to-day, 
fifty-five  years  ago.  Which  of  these  complications, — otitis, 
pneumonia,  enteritis,  or  meningitis, — is  the  primary  one  is 
difficult  to  say  in  most  cases.  To  my  mind,  none  of  them  is, 
in  many  a  case,  the  primary  cause  of  the  general  infection. 
Pneumococcus,  being  present  on  every  healthy  mucous 
membrane,  will  enter  the  circulation  from  any  point,  par- 
ticularly from  the  nose,  on  which,  by  accident  or  disease, 
the  epithelial  cover  is  removed  or  on  which  it  is  disinte- 
grated. Thus  a  meningitis  may  be  the  first  symptom  of  a 
general  pneumococcus  invasion.      It  may  be   followed   by 

364 


OTITIS    MEDIA    IN    CHILDREN 

other  localizations  or  by  general  sepsis.  Persistent  diar- 
rhoea, often  fatal,  is  frequently  observed  in  such  cases. 
Homen  and  Laitinen,  quoted  by  Preysing  from  Ziegler's 
Beitr.,  vol.  xxv.,  caused  hemorrhages  on  serous  membranes 
and  diarrhoeas,  by  injecting  only  the  toxins  of  strepto- 
cocci. 

Meningitis  connected  with  otitis  media  need  not  be  puru- 
lent. Dr.  Francis  Huber  published  a  case  of  otitic  serous 
meningitis  which  recovered  permanently.^  The  patient  was 
a  child  of  two  and  a  half  years,  suffering  from  adenoids 
and  chronic  aural  discharge.  There  were  general  convul- 
sions which  returned  frequently  during  the  ten  days  pre- 
ceding admission.  There  was  semi-consciousness,  the  pupils 
were  dilated,  mainly  the  right;  there  was  convergent  stra- 
bismus and  lateral  nystagmus,  rapid  pulse,  and  taches. 
The  tendon  jerks  were  exaggerated.  On  the  thirteenth 
day  the  mastoid  process  was  opened,  diseased  bone  removed, 
and  the  dura  reached  but  not  opened.  Lumbar  puncture 
was  then  made  twice  in  two  days,  SOccm  and  16  ccm  of 
liquor  were  removed.  It  contained  no  bacteria.  Twenty- 
two  days  afterward  the  child  was  discharged  and  remained 
well. 

In  the  atrophic  infants  the  bone,  with  the  exception  of 
some  parietal  swelling,  was  not  found  to  be  affected.  Even 
in  healthy  children  the  bony  wall  of  the  antrum  is  very 
thin,  and  small  abscesses  are  apt  to  perforate  before  giv- 
ing rise  to  serious  injury. 

PREVENTION 

Nasal,  post-nasal,  and  pharyngeal  catarrh  should  be 
treated  before  they  can  do  harm;  adenoids  removed,  en- 
larged tonsils  resected,  and  hypertrophy  of  the  mucous 
membrane  of  the  nose  attended  to.  No  operation  about 
these  parts  is  successful  unless  subsequent  cleanliness  be 
enforced.  I  have  found  that  some  operators  neglect  to 
avoid  recurrences  by  not  attending  to  that  rule.  One  or 
two  daily  warm  saline  irrigations  made  from  a  nasal  cup, 
during  which  the  mouth  should  be  kept  slightly  open — ■ 
7  Am.  Med.,  1903. 
365 


DR.    JACOBI'S    WORKS 

not  injections — suffice  for  that  purpose.  Adenoids  when 
small  will  get  well  without  operation  when  these  irriga- 
tions are  gently  and  regularly  made.  Sprays  or  the  use 
of  droppers  cannot  take  the  place  of  irrigations.  A  spray 
of  a  .5  per  cent,  solution  of  silver  nitrate  through  the  nares 
once  a  week  will  work  well.  This  application  should  be 
made  several  weeks  in  succession. 

TREATMENT 

A  child  with  an  acute  otitis  media  should  be  in  bed, 
the  head  and  trunk  raised.  The  raising  of  the  head  alone 
may  lead  to  annoyance  of  the  circulation  of  the  neck. 
No  feather  pillows  under  the  head.  Symptoms  will  be 
ameliorated  by  a  mild  antipyretic,  a  narcotic,  a  purgative. 
Politzer  and  Valsalva  are  not  adapted  to  the  acute  stage. 
Severe  pain  may  be  relieved  by  a  few  drops  of  cocaine  solu- 
tion instilled  into  the  ear,  occasionally  by  a  leech  on  the 
mastoid  process.  Warm  fomentations  with  spongiopiline, 
or  simple  warm  wet  cloths  without  or  with  antiseptic  solu- 
tions should  be  tried.  When  pus  forms  the  posterior  half 
of  the  membrane  bulges  first;  at  its  edge  the  hammer  is 
distinguished.  When  an  incision  is  required  it  should  be 
made  posteriorly  and  inferiorly.  The  expulsion  of  the 
pus  through  the  incised  wound  can  be  facilitated  by  Polit- 
zeration,  but  this  procedure  may  drive  pus  into  the  cells. 
Injections  into  the  external  canal  should — if  at  all,  be  made 
toward  the  wall  of  the  canal.  Their  advisability  is  fav- 
ored and  denied  in  equally  strong  terms.  I  do  not  use 
them.  More  than  a  dozen  years  ago  I  learned  from  my 
specialist  friends  the  use  of  boric  acid.  After  the  ear  has 
been  wiped  out  Avith  absorbent  cotton  it  is  filled  loosely 
with  boric  acid.  When  this  is  softened  with  pus,  the  ear 
is  again  cleansed  and  the  process  repeated.  This  proced- 
ure has  proved  so  successful  that  I  remain  true  to  the  ad- 
vice of  my  friends.  I  have  often  been  told  since  that  the 
method  is  bad  and  that  injections  into  the  external  canal 
should  be  preferred,  but  I  have  read  of  deaths  that  have 
occurred  after  injections  in  the  practice  of  such  men  as 
Troeltsch,  Fraenkel,  and  Katz,  and  I  cannot  help  appre- 

366 


OTITIS    MEDIA    IN    CHILDREN 

elating  the  fact  that  enough  people  die  without  our  ag- 
gressive co-operation. 

To  what  extent  sepsis  depending  on  otitis  media,  pure 
or  complicated,  can  be  benefited,  is  uncertain.  Anti- 
streptococcus  serum  is  of  very  doubtful  efficacy.  Crede 
ointment  may  be  used  with  a  certain  amount  of  confidence. 
It  should  be  applied  once  or  twice  a  day.  The  inunction 
should  last  half  an  hour,  and  absorption  facilitated  by  the 
addition  of  a  few  drops  of  water  to  the  ointment.  Col- 
largol  acts  more  rapidly  when  dissolved  in  sterile  water 
and  injected  into  the  rectum.  Large  quantities  of  water, 
drunk,  injected  into  the  rectum,  or  under  the  skin  in  the 
usual  cautious  way,  are  known  to  cause  copious  elimination 
from  the  blood,  and  deserve  all  the  praise  which  has  again 
been  bestowed  upon  them  by  B.  Alexander  Randall  in  an 
article  on  "  The  Treatment  of  Otitic  Septicaemia,"  which 
appeared  in  the  Journal  of  the  American  Medical  Associa- 
tion of  November  26,  1904.  Nuclein  may  be  tried  inter- 
nally. 

A.  Bronner,  of  Bradford,  England,^  publishes  his  opin- 
ion on  the  local  treatment  of  some  forms  of  non-suppurative 
catarrh  of  the  middle  ear  by  compressed  air  and  a  nebulizer, 
recommending  for  the  purpose  the  compressed-air  appara- 
tuses used  in  America.  He  is  careful  enough  to  add  what 
he  takes  to  be  a  fact  that  many  cases  of  so-called  dry 
catarrh  of  the  middle  ear  are  not  due  to  any  affection  of  the 
mucous  membrane  at  all,  but  to  a  primary  disease  of  the 
osseous  labyrinth.  In  these  cases  the  use  of  the  catheter 
can  do  a  great  deal  of  harm.  If  sudden  great  pressure 
be  applied,  the  hearing  and  tinnitus  may  become  worse. 
In  dubious  cases  he  uses  the  catheter  with  an  iodine  spray 
under  very  low  pressure.  It  seems  probable  that  in  many 
of  these  cases  we  have  after  all  to  deal  with  the  results 
of  former  inflammations  that  resulted  in  thickening  of  the 
mucous  membrane.  It  is  in  these  cases,  though  they  be 
not  syphilitic,  that  the  internal  use  of  an  iodid  or  of  "  mixed 
treatment "  may  be  expected  to  do  good.  But  as  a 
rule,  and  that  I  emphasize  more  than  anything  else,  chronic 

?  British  Med.  Journal,  November  5,  1904. 

367 


DR.    JACOBI'S    WORKS 

disease  of  the  mucous  membrane  of  the  ear  will  never  get 
permanently  cured  unless  the  chronic  catarrh  of  the  naso- 
pharynx receive  constant  attention.  After  all,  the  treat- 
ment of  norr-suppurative  disease  of  the  middle  ear  is  rather 
ineffective.  Nothing  is  more  corroborative  of  this  old  ex- 
perience than  the  discussion  lately  held  in  the  British  Med- 
ical Association  by  eighteen  gentlemen,  well-known  in  their 
specialty  and  literature,  a  few  of  them  our  own  fellow- 
countrymen.''  The  latest  paper  on  "  The  Present  Status 
of  the  Treatment  for  Deafness  Due  to  Chronic  Catarrhal 
Otitis  Media,"  published  by  Dr.  Philip  D.  Kerrison  in  the 
Journal  of  the  American  Medical  Association,  November 
12,    1904,   expresses    itself   in   the   same    strain. 

9  British  Med.  Journal,   November   5,  1904. 


368 


NEPHRITIS  OF  THE  NEWBORN 

Nothing  would  have  pleased  me  more  than  to  appear 
before  you,  who  have  kindly  consented  to  listen  to  me  part 
of  an  evening,  with  something  absolutely  new.  The  his- 
tory of  medicine,  however,  exhibits  but  very  few  instances 
of  striking  novelty.  It  is  more  replete  with  the  proofs  of 
a  slow  and  steady  evolution  than  with  sudden  and  un- 
thought-of  revelations.  Still,  there  is  one  peculiar  fea- 
ture both  in  the  study  of  our  science  and  the  practice  of 
our  art — viz.,  that  wherever  we  approach  it  it  is  intensely 
interesting.  That  is  why  even  the  men  borne  down  with 
hard  work,  and  altogether  too  often  near  the  brink  of  men- 
tal and  pIiA'sical  exhaustion  in  the  performance  of  their 
arduous  daily  duties,  are  always  roused  to  enthusiasm  by  a 
single  new  experience,  an  unheard-of  fact,  a  novel  hypothe- 
sis, or  only  a  new  point  of  view  calculated  either  to  enlarge 
their  horizon  or  to  benefit  their  fellow  men. 

To  me  the  connection  of  the  kidneys  with  the  rest  of 
the  organism  has  been  a  subject  of  interest  through  all  my 
professional  life.  These  organs  are  so  intimately  inter- 
woven with  the  whole  physiological  existence  that  either 
their  anatomy  or  their  function  participates  in  every  dis- 
ease of  every  organ.  This  is  particularly  perceptible  in  the 
infectious  diseases,  no  matter  whether  mild  or  severe.  In 
many  of  them  one  of  the  forms  of  nephritis  is  very  com- 
mon. In  scarlatina,  for  instance,  the  desquamative  process 
is  quite  active  in  the  uriniferous  tubes,  and  results  in  a 
peculiar  form  of  inflammation;  in  some  cases  of  scarlatina 
and  most  of  the  other  acute  eruptive  and  infectious  mala- 
dies it  is  parenchymatous  changes  that  are  more  frequently 
met  with.  Thus,  indeed,  it  is  worth  while  to  study  the- 
urine  in  every  case  of  disease.  It  is  true  that  we  are  not 
always  rewarded  with  the  finding  of  severe  lesions;  for, 
happily,  most  of  the  cases  of  secondary  nephritis  are  neither 

369 


DR.    JACOBI'S    WORKS 

dangerous  nor  of  long  duration.  But  there  is  none  of 
them  but  may  lead  to  a  severe  form,  with  possibly  a  fatal 
termination.  Therefore,  the  frequency  of  infectious  dis- 
eases in  infancy  and  childhood  ought  to  fix  our  attention 
constantly  in  the  direction  of  the  kidneys.  It  is  true  that 
sometimes  we  are  unable  to  find  anything  but  albuminuria, 
which,  in  the  absence  of  kidney  elements  under  the  micro- 
scope, we  are  liable  to  dismiss  as  transient  and  of  little 
account.  But  in  this  we  are  very  apt  to  be  mistaken. 
My  cases  of  uncomplicated  and  transient  albuminuria  have 
become  wonderfully  scarce  since  I  invariably  employ  for  the 
examination  of  the  urine  the  centrifuge.  Among  twenty 
successive  cases  where  the  verdict  is  "  trace  of  albumin  "  I 
am  certain  to  find  in  the  centrifuged  deposits  of  nineteen, 
within  a  few  minutes,  the  almost  uniform  result — blood- 
cells,  hyaline  casts,  hyaline  casts  studded  with  epithelia,  or 
finely   or  coarsely   granulated  casts. 

Many  of  these  forms  of  nephritis  are,  as  I  said,  short- 
lived. Quite  often  will  they  disappear  within  a  week  or 
ten  days.  But  this  happy  termination  is  far  from  being 
universal.  There  is  nobody  here  but  has  been  surprised  in 
a  child  of  advanced  age  or  in  an  adolescent  by  an  attack  of 
uraemic  convulsion,  the  cause  of  which  could  be  traced  to  a 
scarlet  fever  which,  six  or  ten  years  ago,  terminated  in  ap- 
parent recovery.  The  same  experience  is  had  with  nephritis 
from  other  causes ;  for,  unfortunately,  we  know  by  this  time 
that  besides  scarlatina,  measles,  varioloid,  and  varicella,  even 
vaccinia,  acute  local  diseases  of  the  skin,  erysipelas,  rheu- 
matism, typhoid  fever,  acute  and  chronic  intestinal  diseases 
may  be  complicated  with  or  followed  by  nephritis.  For 
this  reason  nephritis  is  very  common  in  infancy  and  child- 
hood, and  ought  to  be  searched  for  whenever  the  origin  of 
prominent  or  dangerous  symptoms  is  not  at  once  clear. 
Fortunately,  it  is  easy  to  obtain  a  specimen  of  urine,  for 
catheterization  is  more  readily  successful  in  the  child  than 
in  many  adults.  Thus  it  will  frequently  happen  that  a  ne- 
phritis is  found  when  the  prominent  cerebral  symptoms 
suggested  the  diagnosis  of  encephalitis  or  meningitis.  Of 
the  many  cases  of  this  nature  which  I  have  met  with,  the 
following  will  furnish  an  illustration: 

370 


NEPHRITIS    OF    THE    NEWBORN 

A  boy  of  five  weeks  who  had  appeared  to  be  in  fair 
health  was  taken  with  high  fever  and  convulsions.  The 
case  occurred  in  a  family  living  in  very  moderate  circum- 
stances, therefore,  the  medical  man  had  good  reason  to  sup- 
pose that  the  infant  had  been  ailing  some  days  before  it 
was  considered  necessary  to  call  him  in.  The  temperature 
was  104°  to  105°  F.,  the  pulse  almost  uncountable,  and  the 
convulsions  had  not  been  frequent  when  I  saw  the  ^patient. 
There  was  some  cyanosis  and  perspiration  over  the  upper 
part  of  the  body;  the  legs  and  feet  were  cold,  the  head 
was  very  hot.  There  was  no  oedema.  The  pupils  were 
equal,  fairly  dilated,  contracted  a  very  little,  but  slug- 
gishly, under  the  influence  of  a  strong  ray  of  light,  and 
under  the  same  light  dilated  again  and  contracted  within 
certain  limits.  The  equality  of  the  pupils,  combined  with 
that  peculiar  floating  condition  of  the  iris,  made  me  think 
of  uraemia  as  the  cause  of  all  the  cerebral  symptoms.  The 
urine  was  known  to  be  scanty,  but  that  is  what  it  also  is 
in  meningitis,  and  in  every  child  that  has  not  been  supplied 
with  a  sufficient  quantity  of  water.  Fortunately,  there  was 
some  in  the  bladder.  Boiling  almost  solidified  it,  and  the 
microscope  revealed  blood-cells,  epithelial  and  granular 
casts,  the  latter  both  fine  and  coarse.  The  child  died;  no 
autopsy  could  be  had.  No  clew  could  be  found  to  the 
causation  of  the  fatal  disease;  and  still,  the  baby  was  so 
young  that  in  all  probability  the  origin  of  the  fatal  ne- 
phritis might  have  been  found  in  some  occurrence  of  the 
first  few  days  of  life. 

It  is  this  period  of  early  life  to  which  I  mean  to  direct 
your  special  attention  to-night  by  reporting  a  few  of  the 
many  cases  of  nephritis  met  with  within  a  few  days  or 
weeks  after  birth.  Some  are  primarily  renal  diseases,  some 
are  secondary.  To  the  latter  class  belong  those  nephritides 
which  are  complicated  with  or  dependent  upon  intestinal 
disorders.  This  connection  is  quite  frequent.  In  many 
instances  diarrhoeal  disorders  are  the  results  of  nephritis, 
but  quite  frequently  both  acute  and  chronic  intestinal  dis- 
eases appear  to  be  the  causes  of  nephritis,  which  may  be 
quite  ominous;  for  indeed  it  is  here  as  in  other  diseases, 

371 


DR.    JACOBI'S    WORKS 

many  of  which  are  liable  to  terminate  fatally  by  their  renal 
complication.  Every  practitioner  loses  many  a  case  of 
pneumonia,  not  through  the  severity  of  the  pulmonary 
lesion,  but  on  account  of  the  accompanying  nephritis.  In 
this  way  the  entero-colitis  of  the  newborn  is  quite  apt  to 
destroy  life  through  nephritis.  In  a  highly  creditable 
essay  (Arch.  f.  Kinderk.,  1894,  xvii,  p.  222)  Felsenthal  and 
Bernhard  have  studied  the  connection  of  nephritis  with 
acute  and  chronic  intestinal  disorders  of  infancy  and  child- 
hood. They  have  also  collected  the  literature  on  the  sub- 
ject. Parrot  met  with  it  in  the  atrophy  ("  athrepsia  ")  of 
young  infants;  Kjellberg,  Fischl,  Stiller,  Baginsk}',  Hirsch- 
sprung, Hagenbach,  Henoch,  Epstein,  and  others  have 
recorded  cases  of  nephritis  accompanying  intestinal  dis- 
orders. The  cases  of  this  description  are  by  no  means  rare 
in  the  first  week  of  life.  When  I  look  over  the  list  of  the 
numerous  cases  of  the  kind  I  have  personally  seen,  it  al- 
most seems  to  me  supererogation  to  record  a  case ;  and  still 
I  know  that  many  of  my  colleagues  with  whom  I  saw  the 
cases  appeared  to  be  surprised  at  recognizing  both  the 
presence  of  nephritis  in  such  cases  and  the  facility  with 
which  the  diagnosis  could  be  made. 

The  literature  on  the  subject  is  but  scanty.  I  have, 
however,  reason  to  believe  that  even  those  who  have  known 
the  connection  between  intestinal  diseases  and  nephritis 
quite  well  have  not  published  their  experience.  It  has  hap- 
pened to  me  personally  that  my  chapters  on  catarrh  and 
ulceration  of  the  bowels  in  my  Intestinal  Diseases  of  In- 
fancy and  Childhood,  1887,  are  silent  on  that  subject  by 
an  oversight  of  my  own.  But  in  the  discussion  on  Two 
Cases  of  Acute  Primary  Nephritis  in  Infancy,  by  L.  Em- 
mett  Holt,  one  of  which  was  perhaps  caused  by  intestinal 
sepsis  without  that  explanation  being  suspected,  I  took 
occasion  to  say  (Trans,  of  the  Am.  Peed.  Soc,  1891,  vol. 
iii,  p.  233)  :  "  There  are  cases  of  nephritis  which  compli- 
cate intestinal  diseases.  It  is  true  that  many  spells  of 
vomiting  and  diarrhoea  are  merely  symptoms  of  nephritis. 
A  number  of  cases  supposed  to  be  cholera,  even  Asiatic, 
are  found  to  be  acute  nephritis.  On  the  other  hand,  where 
we  have  to  do  with  an  acute  or  subacute  intestinal  catarrh, 

372 


NEPHRITIS    OF    THE    NEWBORN 

a  prolonged  seizure  may  give  rise  to  secondary  nephritis. 
I  am  positive  that  it  will  be  found  to  be  much  more  fre- 
quent than  it  was  considered  to  be."  In  the  Archives  of 
Paediatrics,  June,  1890,  p.  420,  diarrhoea  is  also  briefly 
mentioned  by  me  as  one  of  the  many  causes  of  nephritis. 

It  is  but  two  years  ago  that  a  colleague  presented  a  boy, 
five  days  old,  the  child  of  very  poor  parents,  at  my  office. 
The  cord  had  fallen  off"  and  the  stump  looked  normal.  The 
mouth  was  slightly  covered  with  sprue.  The  lips,  fingers, 
and  toes  were  cyanotic,  though  the  feeble  heart  appeared 
normal;  the  baby  was  nearly  collapsed.  Rectal  tempera- 
ture, 103°  F.  For  two  days  there  had  been  loose  mucous 
discharges  in  great  numbers ;  they  were  slightly  off'ensive, 
did  not  contain  meconium  any  more,  but  already  at  that 
early  time  coagulated  masses  of  casein.  There  was  no 
tenesmus  and  no  blood.  The  urine  of  the  second  and 
third  day  appeared  to  the  attendants  darker  than  normal; 
during  the  last  day  but  little  had  been  passed.  We  drew 
about  ten  cubic  centimetres  of  a  dark,  smoke-colored  fluid. 
It  contained  albumin  in  great  quantity,  and  under  the  mi- 
croscope blood-cells,  epithelial  and  granular  casts,  and 
urates.     The  baby  died  the  following  day.     No  autopsy. 

It  was  a  similar  case  that  I  saw  with  the  same  gentle- 
man a  few  months  afterward.  He  made  the  diagnosis  be- 
fore I  met  him.  It  proved  one  of  the  most  fortunate  I 
have  seen;  firstly,  because  it  was  not  so  severe  as  the  for- 
mer, and,  secondly,  because  there  was  ample  time  to  restore 
and  equalize  by  warm  bathing  both  the  cutaneous  and  gen- 
eral circulation,  to  cleanse  and  disinfect  the  intestine  and 
fill  the  blood-vessels,  to  establish  a  flow  of  urine  through 
the  uriniferous  tubes  by  means  of  copious  and  frequent  irri- 
gations of  the  bowels,  and  to  stimulate  the  heart  by  judi- 
cious doses  of  strychnine,  of  which  the  infant  took  nearly  a 
milligramme   during  twenty-four   hours. 

What  little  I  have  said  of  the  nature  of  the  discharges, 
their  off"ensiv€ness  and  frequency,  suggests  the  cause  of 
the  secondary  nephritis.  It  evidently  depends  on  the  ab- 
sorption of  a  toxine,  no  matter  whether  it  originates  in  the 

S73 


DR.    JACOBI'S    WORKS 

invasion  of  a  streptococcus,  or  of  the  bacterium  coli,  or  one 
of  the  other  forms  of  microbes  detailed  by  Booker  and  by 
Jeffries  in  the  Transactions  of  the  American  Pediatric  So- 
ciety of  1889. 

Their  absorption  is  facilitated  by  some  peculiar  anatom- 
ical conditions. 

The  muscular  apparatus  of  the  intestine  of  the  foetus 
and  of  the  newborn  is  but  slightly  developed.  During 
foetal  life  its  function  is  but  trifling,  and  its  contents  move 
but  slowly.  Immediately  after  birth  that  muscular  debility 
predisposes  to  colic,  as  air  which  is  swallowed;  and  gases, 
both  innocuous  and  putrid,  which  are  developed  in  the  tract, 
are  expelled  with  difficulty.  Besides,  the  infantile  digest- 
ive tract  is  unexpectedly  long.  According  to  Beneke,  the 
proportion  of  the  length  of  the  body  to  that  of  the  small 
intestine  is  in  the  adult  100  to  450;  in  the  newborn, 
however,  100  to  570;  in  the  second  year,  100  to  660. 
Moreover,  the  villi  are  generally  numerous  and  large;  some 
assert  they  surpass  in  size  those  found  in  the  adult  intes- 
tine; the  capillaries  of  the  villi,  it  is  claimed,  have  greater 
absolute  size,  so  much  so  that  their  diameter  is  larger  than 
that  of  the  same  vessels  in  the  adult.^  All  this  tends  to 
show  that  both  the  accumulation  of  septic  material  in,  and 
absorption  from,  the  interior  of  the  intestines  is  rendered 
very  easy.  The  access  of  microbes  to  the  intestinal  tract 
of  the  newborn  is  by  no  means  difficult.  How  they  en- 
ter, through  the  mouth,  the  anus,  or  the  blood,  I  have  but 
recently  discussed  in  the  first  number  of  Pcediatrics.  Af- 
ter all,  it  seems  that  the  nephritis  originating  from  in- 
testinal infection  is  of  a  similar  nature  to  what  we  ob- 
serve in  typhoid  fever  oi^  any  of  the  other  infectious 
diseases. 

Nephritis  in  typhoid  fever  of  the  newborn  I  have  seen 
but  once,  for  the  simple  reason  that  I  have  observed  but 
this  one  case  of  typhoid  fever  in  one  so  young.  It  was 
cursorily  mentioned  on  page  29  of  my  Treatise  on  Diphthe- 
ria, 1880.     The  baby  died  on  the  sixteenth  day  of  its  life, 

1  A.  Jacobi.  Intest.  Dis.  of  Infancy  and  Childhood.  George 
S.   Davis,   1887.     Chapter  on  Intestinal  Digestion. 

374 


NEPHRITIS    OF    THE    NEWBORN 

twenty-two  years  ago.  The  mother  recovered.  Its  kid- 
neys were  much  congested,  the  two  substances  hardly  dis- 
cernible from  each  other,  and  blood  oozed  from  the  cut 
surfaces.  There  had  been  anuria  for  two  days,  and  no  urine 
was  found  in  the  bladder  after  death. 

In  one  of  the  three  cases  of  diphtheria  in  the  new- 
born, reported  on  page  30  of  my  Treatise,  I  was  favored 
with  an  autopsy.  The  baby  was  taken  seven  days  after 
birth  and  died  on  the  ninth.  The  kidneys  were  in  the 
condition  described  in  the  previous  case.  No  microscopical 
examination  of  the  urine  could  be  had. 

In  connection  with  this  subject  I  now  present  the  case 
of  the  youngest  patient  I  have  seen  destroyed  by  potassic 
chlorate. 

B.  C,  a  boy  of  nine  days,  was  seized,  January  15,  1882, 
with  convulsions,  after  not  having  voided  urine  for  several 
hours.  The  last  time,  when  a  teaspoonful  was  passed,  it  was 
of  a  dark  color,  stained  the  napkin,  and  seemed  to  give  pain 
during  the  discharge.  There  was  constant  rectal  tenesmus, 
with  some  protrusion  of  the  bowels,  some  five  or  six  hours 
before  the  convulsion.  During  all  this  time  the  complexion 
was  sallow,  and  the  lips  and  finger  and  toe  nails  were  blue. 
I  saw  the  infant  after  the  convulsions,  with  hardly  a  pulse, 
bluish  lips,  brownish  complexion,  the  sclerae  still  yellow  and 
largely  ingested  with  dilated  blood-vessels.  Heart  beats  from 
200  to  220  a  minute,  scarcely  perceptible.  Within  an  hour 
after  my  visit  he  died.  The  blood  in  the  whole  body  was  of 
an  intensely  dark  color,  the  heart  of  normal  size  and  struc- 
ture, ductus  Botalli  nearly  closed,  ductus  venosus  Arantii 
still  open.  Lungs  and  spleen  were  engorged  and  purplish,  so 
was  the  liver.  The  kidneys  were  large;  a  number  of  blood 
points — small  haemorrhages — were  visible  on  the  longitud- 
inal section;  there  were,  besides,  a  number  of  dark  streaks 
corresponding  with  the  uriniferous  tubes,  and  the  diff"erence 
between  the  two  renal  substances  was  almost  extinct.  Their 
color  was  unusually  dark,  and  they  offered  a  strongly 
marked  elastic  resistance  to  the  touch.  What  little  urine 
(about  two  cubic  centimetres)  was  taken  from  the  bladder 
contained  much  pelvic  epithelium,  and  consisted  almost  ex- 
clusively of  decomposed  blood-cells, 

875 


DR.    JACOBI'S    WORKS 

The  great  resemblance  of  this  form  of  nephritis  to  what  I 
had  described  in  the  third  volume  of  Gerhardt's  Handbuch 
der  Kinderkrankheiten,  article  Diphtheria,  in  1877,  and  in  a 
paper  on  The  Remedial  and  Poisonous  Effects  of  Chlorate 
of  Potassium,  published  in  the  Medical  Record  of  March 
15,  1879j  made  me  inquire  rather  scrupulously  into  the  his- 
tory of  the  dead  baby.  The  mother  had  suffered  from  copi- 
ous vaginal  discharge  during  the  last  few  months  of  her 
pregnancy.  Neither  she  nor  her  surroundings  were  of  the 
cleanest.  The  first  few  days  of  the  infant's  life  were  nor- 
mal. On  the  third  and  fourth  day  sprue  developed  and 
covered  lips  and  cheeks  with  thick  deposits.  The  midwife 
in  charge  called  no  physician.  She  knew  the  best  thing  for 
sprue  and  inflicted  it.  She  brushed  the  mouth  with  a  satu- 
rated solution  of  potassic  chlorate,  as  she  proudly  asserted, 
quite  often,  and  frequently  gave  a  few  drops  to  drink.  I 
could  not  learn  the  strength  of  her  solution.  She  always 
used  it  and  it  had  a  powerful  effect,  she  said.  As  far  as 
I  was  permitted  to  learn,  she  dissolved  a  tablespoonful  in 
a  tumblerful  of  water;  I  still  found  a  sediment  of  the  salt 
in  the  bottom  of  a  tumbler. 

A  case  of  nephritis  after  vaccination  was  reported  by 
Perl  in  the  Berliner  klinische  Wochenschrift,  1893,  No. 
28.  It  behaved  exactly  as  nephritis  in  infectious  fevers. 
The  child,  two  years  and  nine  months  old,  became  very 
restless  about  the  usual  time  of  the  onset  of  a  vaccinia 
fever — viz.,  from  the  fourth  to  the  fifth  day;  at  the  same 
time  there  seemed  to  be  abdominal  and  lumbar  pains. 
Within  a  day  after,  simultaneously  with  the  appearance  of 
six  vaccination  vesicles,  there  was  albumin  in  the  urine  to 
the  amount  of  one  half  of  a  per  mille;  also  haematin, 
blood-cells,  and  some  leucocytes.  The  casts  were  either 
purely  hyaline,  or  hyaline  studded  with  epithelium.  The 
child  was  well  on  the  twelfth  day.  The  whole  morbid  proc- 
ess ran  its  full  course  in  six  days,  with  no  serious  symp- 
toms at  all. 

The  following  is  a  case  of  a  similar  description  in  a 
very  young  infant: 

In  an  immigrant  hotel  of  Greenwich  Street,  New  York,  I 
saw  with  Dr.  John  Bishop,  April  4,  1877,  two  children,  one 

376 


NEPHRITIS    OF    THE    NEWBORN 

of  four  years  and  one  of  three  weeks,  who  had  been  vacci- 
nated ten  days  previously.  I  was  expected  to  see  the  older 
one,  who  had  an  erysipelas  of  moderate  size  and  severity;  it 
got  well  after  twice  traveling  over  the  surface  of  the  body. 
On  the  very  day  of  my  visit  the  baby,  who  had  run  through 
her  vaccinia  fever  with  no  unusual  discomfort,  was  seized 
with  an  attack  of  convulsions.  When  I  saw  her  there  was 
a  rectal  temperature  of  103°,  a  dazed  look,  injected  con- 
junctivae, pupils  equal,  somewhat  dilated,  and  floating  un- 
der the  influence  of  light.  The  latter  symptoms  induced  me 
to  draw  urine  and  examine  it.  It  was  scanty  and  contained 
a  trace  of  albumin,  a  few  blood-cells,  and  hyaline  and 
finely  granular  casts.  This  nephritis  lasted  two  weeks  be- 
fore it  finally  disappeared.  During  all  this  time  there 
was  no  other  convulsion,  no  oedema,  but  an  occasional  vomit- 
ing spell  and  diarrhoea  during  the  first  week  of  the  illness; 
the  pupil  symptom  persisted ;  the  temperature  varied  be- 
tween 101°  and  103°,  a  moderate  remission  taking  place 
in  the  morning.  During  the  second  (and  last)  week  of 
the  disease  all  the  above  symptoms  gradually  disappeared, 
and  the  temperature  went  down.  In  their  place  a  slight 
oedema  of  the  lower  extremities  and  of  the  face  was  ob- 
served. The  microscopical  changes  in  the  condition  of  the 
urine  remained  the  same  about  ten  days  after  they  were  first 
discovered.  Then  they  disappeared,  and  recovery  remained 
undisturbed. 

Renal  disorders,  more  or  less  dangerous,  are  direct  re- 
sults of  sudden  changes  in  the  circulation,  without  or  with 
visible  alterations  of  the  blood.  To  the  first  class  belongs 
a  case  I  once  saw  with  a  medical  friend  who  had  so  much 
confidence  in  the  vitality  and  vigor  of  the  newborn  that 
he  commenced  to  enforce  his  theories  on  the  necessity  of 
early  hardening  immediately  after  birth.  He  would  plunge 
the  newcomers  into  cold  water,  and  feel  a  grim  delight  in 
taking  their  incipient  breath  away  and  making  them  shriek 
in  reflex  self-defense.  Two  of  his  victims  I  saw  with  him; 
they  died  within  a  fortnight.  The  second  we  examined 
post  mortem.  There  was  a  pneumonia,  it  is  true,  perhaps 
sufficient  to  destroy  life.  But  the  most  apparent  and  prob- 
able cause  of  death,  preceded  by  suppression  of  urine,  was 

377 


DR.    JACOBI'S    WORKS 

evidently  bilateral  nephritis.  Both  the  kidneys  were  large, 
intensely  congested,  and  blood  poured  out  of  the  cuts; 
the  difference  between  the  two  substances  could  not  be  dis- 
tinguished. With  him  I  saw  no  more  such  cases,  for  I  sug- 
gested the  probability  that  the  cold  bathing  of  the  new- 
born furnished  us  the  specimen.  But  the  more  I  have  seen 
of  similar  cases  in  the  adult,  the  more  do  I  feel  that  I  was 
correct  in  my  charge.  For  acute  nephritis,  interstitial, 
sometimes  haemorrhagic,  is  an  occasionally  unavoidable 
occurrence  in  sudden  suppression  of  cutaneous  circulation. 
Who  has  not  seen  death  occurring  from  nephritis,  not  pre- 
ceded by  a  chronic  affection,  in  persons  who  have  been  re- 
suscitated from  drowning  in  an  ice-cold  river,  or  have  been 
exposed  to  a  driving  rain  storm  while  exerting  themselves 
to  get  under  shelter,  or  to  cold  and  sleet  in  an  open  sleigh? 
What  the  slow  influence  of  cold  can  not  accomplish  in  the 
healthy  and  vigorous,  what  not  even  a  nephrectomy  can  ac- 
complish in  the  remaining  kidney,  its  sudden  effect  on  the 
feeble,  or  fatigued,  or  even  the  vigorous,  will  easily  bring 
about.  No  matter  whether  the  reasons  are  to  be  sought 
for  in  an  antagonism  of  the  skin  and  kidneys,  or  the  en- 
forced elimination  of  cutaneous  excrements  through  the 
kidneys,  the  facts  are  actual.  Moreover,  direct  experiments 
made  by  Lassar  unmistakably  prove  the  causation  of  inter- 
stitial inflammation  by  sudden  refrigeration. 

Like  excessive  cold,  heat  may  lead  to  nephritis  and 
death.  Only  once  have  I  seen  a  newborn  sacrificed  in 
that  way  through  his  first  bath.  The  midwife  evidently  had 
anaesthesia  or  analgesia.  Bystanders  noticed  the  steaming  of 
the  water  in  the  bath  tub,  the  suffering  of  the  suffocating 
baby,  his  livid  appearance;  and  the  raising  of  large  blis- 
ters on  the  surface  told  the  story.  The  baby  died  within 
a  day,  having  lost  some  blood  mixed  with  meconium  and 
passed  no  urine.  Even  the  bladder  was  empty  at  the 
autopsy,  and  deeply  congested.  The  kidneys  were  livid 
and  succulent;  blood  oozed  out  of  the  cut  surfaces.  Blood 
was  also  extravasated  under  the  capsules.  If  the  case  had 
run  a  longer  course,  in  all  probability  haemoglobinuria, 
produced  by  dissolution  of  blood-corpuscles,  would  have 
shown  itself,  as  in  the  experimental  researches  of  Ponfick 

878 


NEPHRITIS    OF    THE    NEWBORN 

and  of  Wertheim.  Changes  in  the  general  circulation  need 
not,  however,  be  of  this  sudden  and  violent  type,  and  still 
result  in  some  injury. 

Indeed,  the  albuminuria  of  the  newborn  is  frequently 
due  to  the  insufficiency  of  circulation,  and  passes  off  when 
the  latter  is  freely  established;  just  as  the  venous  obstruc- 
tion caused  by  heart  or  lung  disease  results  in  temporary 
albuminuria  in  the  adult.  In  a  certain  number  of  these 
cases  of  almost  congenital  albuminuria  there  is  no  blood 
under  the  microscope,  in  others  there  is,  in  others  there  is 
more — viz.,  nephritis.  It  is  probable  that  after  most  cases 
of  protracted  asphyxia  of  the  newborn  albumin  will  be 
found  in  the  urine,  with  or  without  blood.  Thus  the  kid- 
neys repeat  but  the  process  which  has  been  so  much  bet- 
ter studied  in  the  brain  by  Langdon  Down-  and  also  by 
me.^ 

Indeed,  in  three  cases  of  nephritis,  two  of  which  proved 
fatal,  observed  within  five  weeks  after  birth,  no  aetiology 
except  that  of  previous  long-continued  asphyxia  could  be 
elicited.  It  was  in  those  two  that  granular  and  coarse 
casts  were  in  the  majority;  in  the  one  which  survived, 
there  was  still  after  weeks  blood  and  a  few  epithelial  and 
finely  granular  casts. 

In  congenital  heart  diseases  with  cyanosis,  albuminuria 
is  quite  common.  Again  I  warn  against  the  facility  of 
overlooking  it.  Time  and  again  I  am  told  there  is  no 
albumin  in  a  specimen;  time  and  again  there  is  in  such 
cases  a  trace,  which  is  called  "  only  a  trace,"  but  yields 
fields  full  of  different  casts  in  the  centrifugal  specimen. 
This  very  trace  is  sometimes  not  discovered  unless  the  test 
tube  be  looked  at  through  water,  and  unless  some  little 
time  is  given  for  the  coagulation  to  become  visible.  Ne- 
phritis does  not  always  work  with  heavy  loads  of  albumin; 
that  the  last  stage  of  chronic  nephritis  of  any  period  of 
life  may  be  without  albuminuria  for  weeks  in  succession 
need  not  be  retold. 

I  once  saw  a  baby  of  four  months,  who  had  spina  bifida 

2  Transactions  of  the  Obstetrical  Society,  London,  1876. 

3  American  Journal  of  Obstetrics,  xxiv,   1891,   No.  6. 

379 


DR.    JACOBI'S    WORKS 

and  consecutive  paralysis  and  contractures  of  both  lower 
extremities,  die  with  nephritis.  We  seldom  see  our  patients 
with  spina  bifida  when  they  breathe  their  last;  for,  until  a 
brief  time  ago,  most  of  them  were  left  to  die  without  an 
attempt  at  relieving  them,  and  a  neighboring  medical  man 
was  called  in  at  the  last  minute  so  that  a  certificate  of  death 
might  be  obtained.  The  same  opportunity  of  observing  a 
fatal  case  of  nephritis  in  a  little  girl  of  three  months  I  had 
about  the  same  time.  The  patient  had  a  paralysis  of  both 
lower  extremities,  dating  from  birth,  and  occasioned, 
probably,  by  an  intraspinal  haemorrhage  caused  during 
difficult  extraction  in  breech  presentation.  Maybe  I  am 
correct  when  in  both  cases  I  attribute  the  renal  changes, 
chronic  in  character,  to  the  fact  that  the  circulation  being 
impeded  by  the  muscular  inactivity  of  a  large  part  of  the 
body  was  more  directed  toward  the  internal  organs.  Maybe, 
however,  this  suggestion  does  not  appear  acceptable,*  for 
it  is  possible  to  assume  that  the  same  violence  which  caused 
a  spinal  haemorrhage  and  paraplegia  was  sufficient  to 
produce  the  same  effect  in  the  kidneys. 

In  the  newborn  we  observe  not  only  the  adverse  re- 
sults of  the  sudden  changes  from  foetal  to  post-natal  circu- 
lation, but  also  lesions  depending  upon  the  peculiar  struc- 
ture of  the  blood-vessels.  The  newborn  is  removed 
from  the  embryo  and  fcEtus  by  a  single  station  only.  Its 
tissues  are  in  part  still  embryonic,  and  endowed  with  less 
solid  structure.  This  is  why  haemorrhages  are  so  very 
frequent  in  the  newborn.  Meningeal  haemorrhages  are 
most  frequent  during  the  first  week,  and  the  slight  coagu- 
lability of  the  blood  of  the  newborn  adds  to  its  dangers. 
In  regard  to  the  brain,  I  have  considered  this  question 
years  ago,  and  frequently  since,  mostly  in  connection  with 
asphyxia  in  the  newborn.  A  large  number  of  cases  of 
idiocy,  epilepsy,  paralysis,  and  insanity  in  the  very  young 
are  due  to  meningeal  haemorrhage  of  early  days  often  ush- 
ered  in  by   asphjWfia.      Similar   occurrences  take   place   in 

4  As  above  stated,  not  even  the  removal  of  a  whole  kidney 
results  in  a  nephritis  of  the  other, 

380 


NEPHRITIS    OF    THE    NEWBORN 

other  organs.  Disseminated  pleural  and  pericardial  haem- 
orrhages are  quite  frequent  in  the  newborn  under  the 
influence  of  retarded  or  interrupted  circulation.  When  the 
latter  improves,  the  haemorrhagic  points  may  become  ab- 
sorbed.    So  it  is  in  the  kidneys. 

Parenchymatous  hcemorrhages  are  capable  of  causing  in- 
flammation in  the  kidneys  as  they  do  in  other  organs.  In 
many  cases,  however,  they  prove  innocuous.  In  the  muscles, 
the  brain,  the  lungs,  extravasations  take  place  without  leav- 
ing any  trace  behind.  It  is  probable  that  whenever  no 
healthy  tissue  is  torn,  when  an  extravasation  takes  place  be- 
tween fibrillae,  absorption  takes  place.  When  there  is,  how- 
ever, an  actual  lesion  of  tissue,  a  secondary  inflammation  is 
or  may  be  the  consequence.  Many  years  ago  I  was  startled 
by  an  acute  nephritis  appearing  in  a  delicate  but  healthy 
boy  of  four  years,  the  son  of  a  well-known  practitioner  in 
New  York.  None  of  the  usual  causes  of  the  disease  could 
be  traced,  and  I  was  perfectly  at  sea  until  a  crop  of  pete- 
chiae  appeared  over  the  chest  and  the  extremities.  I  then 
learned  that  six  months  previously  the  child  had  had  another 
attack  of  purpura  which  gave  rise  to  no  symptoms,  and 
that  a  few  days  before  the  first  symptoms  of  this  acute 
renal  disorder  there  had  been  a  few  petechias  all  over  the 
surface.  The  urine  showed  under  the  miscroscope  rather 
an  unusual  amount  of  blood,  together  with  plenty  of  blood 
casts  and  granular  casts.  It  struck  me,  therefore,  that  the 
nephritis  was  in  this  case  due  to  disseminated  renal  haemor- 
rhages, and  I  ventured  to  give  a  rather  favorable  prognosis. 
It  took  but  a  few  weeks  before  the  patient  had  fully  recov- 
ered. Two  similar  cases  have  been  encountered  since,  one 
in  a  girl  of  seven,  one  of  eleven  years.  Both  recovered. 
Never  before  did  it  occur  to  me  to  look  upon  the  kidneys 
as  more  than  very  rare  participants  in  a  purpuric  process, 
except  in  cases  of  actual  haematuria. 

In  two  newborn  infants  I  have  seen  similar  processes 
originating  from  the  same  source.  A  boy  of  five  days 
was  seen  for  melcena  on  his  fifth  day.  There  was  vomiting 
of  blood;  there  were  bloody  stools.  Their  color  was  not 
quite  black;  some  of  the  blood  was  red,  and  its  origin  could 

381 


DR.    JACOBI'S    WORKS 

be  assigned  to  the  lower  part  of  the  intestinal  tract.  The 
baby  appeared  to  recover  a  little  from  the  sudden  shock  of 
the  loss  of  blood,  when,  on  the  next  day,  slight  traces  of 
blood  appeared  in  the  urine.  Part  of  the  blood  cells  were 
tolerably  normal.  Within  another  day  the  quantity  of 
urine  diminished  greatly  and  assumed  a  smoky  hue.  The 
microscope  still  revealed  blood  cells,  but  also  blood  casts, 
a  very  few  epithelial  and  many  more  finely  granular  casts. 
The  baby  died  and  the  kidneys  were  removed.  Both  of 
them  were  markedly  congested.  On  the  walls  of  the  pelvis 
were  superficial  haemorrhages ;  sections  revealed  a  number 
of  rather  fresh  blood  points.  There  was  no  doubt  in  the 
minds  of  all  those  present  that  the  nephritis  in  this  case 
was  due  to  the  irritation  set  up  by  the  local  haemorrhages. 
Another  case  dates  twenty-six  years  back.  After  a 
protracted  labor  a  boy  was  born  in  breech  presentation. 
Ecchymos€s  over  the  abdomen  proved  the  difficulty  of 
parturition  and  the  summary  procedures  of  the  midwife  in 
charge.  Almost  the  first  urine  voided  by  the  infant  was 
bloody,  and  the  diagnosis  of  traumatic  renal  haemorrhage 
appeared  justified.  Within  a  day  the  blood  disappeared 
almost  entirely,  and  urine  became  suppressed.  The  baby 
died  on  the  fourth  day,  and  was  subjected  to  a  coroner's 
inquest.  There  was  a  moderate  amount  of  blood  clot  under 
the  peritoneal  covering  of  the  liver,  the  liver  was  torn  to  a 
distance  of  about  three  centimetres,  the  peritonaeum  slightly 
torn,  and  blood  had  escaped  into  the  abdominal  cav- 
ity. Both  kidneys  were  large,  dark,  and  blood-stained  on 
section;  the  two  substances  hardly  differed  from  each 
other. 

These  were  extreme  cases,  and  their  diagnosis  was  in  a 
short  time  followed  by  death.  How  many  there  may  occur 
in  which  extravasation  is  but  moderate,  and  the  amount  of 
local  or  perhaps  unilateral  nephritis  is  not  immediately 
fatal,  perhaps  even  inclined  to  get  well,  is  difficult  to  say. 
Large  maternities,  however,  and  foundling  institutions  are 
better  prepared  for  observing  such  occurrences  than  the 
practitioner  engaged  in  private  or  consulting  work. 

Frequent  causes  of  nephritis  of  the  newborn  are  uric- 
acid    infarctions.      They    occur    from    the    second    to    the 

382 


NEPHRITIS    OF    THE    NEWBORN 

twenty-third  day,  but  also  before  birth. ^  They  are  of  dif- 
ferent varieties.  In  a  part  or  in  all  of  the  straight  urinif- 
erous  tubes  there  are  found  yellowish-red  or  brownish, 
spherical  or  angular  bodies  in  such  quantities  as  to  form 
considerable  deposits  and,  when  they  are  discharged  dur- 
ing life,  to  cause  large  stains  of  more  or  less  solidity  in  the 
napkins.  They  are  in  rare  cases  accompanied  with  blood. 
They  consist  of  uric  acid  and  of  ammonium  urate.  The 
latter  is  readily  soluble  in  acetic  acid,  from  which  uric  acid 
crystallizes  in  rhombic  shapes.  In  one  case  Ebstein  met  in 
the  tubuli  contorti  with  yellow  globules  consisting  of  uric 
acid  and  an  organic  stroma  which  contained  no  mucus,  but 
consisted  of  albuminoids  which  were  soluble  in  acetic  acid, 
and  exhibited  either  a  concentric  structure  or  irregular 
layers.  At  once  the  question  rises  in  our  minds  as  to  the 
nature  of  this  organic  stroma.  It  must  strike  us  that  it  can 
be  of  either  of  two  origins.  It  is  either  depending  on  a 
cause  not  connected  with  the  presence  of  the  uric-acid  in- 
farction, or  it  is  the  direct  consequence  of  a  local  irritation 
caused  by  the  deposit — viz.,  secondary  exudation.  In  this 
manner  that  form  of  infarction  would,  by  itself  alone,  ex- 
hibit a  mild  degree  of  nephritis. 

A  second  form  of  renal  infarctions  is  of  a  hoemor- 
rhagic  and  pigmentous  nature.  They  look  very  much  like 
those  already  described,  and  are  found  in  the  same  locali- 
ties.    They  are  granular,  spherical,  or  irregular  conglomer- 

5  Virchow's  original  opinion,  according  to  which  the  presence 
of  uric-acid  infarction  requires  a  certain  duration  of  life,  has 
been  to  a  certain  extent  rescinded  by  the  proof  furnished  by  a 
premature  and  stillborn  foetus  which  contained  uric  acid  in  its 
its  urine  and  urate  of  ammonium  as  sediment.  Moreover, 
well-developed  uric-acid  infarctions  were  observed  by  Martin 
(^Jenaische  Ann.,  1650)  in  a  foetus  born  in  the  unruptured  mem- 
branes after  an  unsuccessful  attempt  at  respiration.  Hoogeweg 
(Casper,  Viertelj.,  1855)  met  with  them  in  an  infant  whose 
heart  ceased  to  beat  three  quarters  of  an  hour  before  delivery. 
Birch-Hirschfeld  has  a  similar  case,  and  Hofmann  (Gerichtl. 
Med.,  fifth  ed.,  1891,  p.  748)  published  the  cases  of  two  infants, 
one  of  whom  lived  but  twenty-three  hours,  the  other  only  fifteen 
minutes,  who  exhibited  uric-acid  infarctions  in  full  development. 

383 


DR.    JACOBI'S    WORKS 

ates,  which  contain  crystals  of  haemotoidin.  They  are  the 
results  of  small  extravasations  originating  in  general  hy- 
peraemia  of  the  canaliculi,  and  depend  on  various  causes,  to 
the  principal  of  which  I  shall  return.  The  usual  changes 
of  haematin  alter  the  color  of  these  deposits,  which  contain 
no  crystals  of  uric  acid  or  ammonium  urate,  and  are  not 
affected  by  acetic  acid.® 

Calcareous  deposits  are  also  found  in  the  newborn. 
They  occur  mainly  in  the  lower  end  of  the  straight  cana- 
liculi,  near  the  papillae,  are  of  a  whitish  color,  and  may, 
therefore,  be  mistaken  on  inspection  for  interstitial  indura- 
tions. They  are  mostly  either  carbonate  or  phosphate  of 
calcium,  but  rarely  triple  phosphate,  and  are  soluble  in 
dilute  hydrochloric  acid.  They  are,  under  favorable  cir- 
cumstances, deposited  into  and  upon  the  epithelia. 

Which  are  these  favorable  circumstances?  Both  phos- 
phates and  carbonates  of  calcium  are  known  to  be  deposited 
from  the  blood  whenever  circulation  is  retarded  or  im- 
peded; for  instance,  in  the  older  baby  in  the  latter  stages 
of  epiphyseal  rhachitis.  In  the  newborn  the  circulation 
is  retarded  or  impeded  by  congenital  (or  rapidly  acquired) 
heart  disease,  by  general  debility,  or  by  asphyxia.  As  early 
as  1883  (Virch.  Arch.)  Litten  counted  among  such  favor- 
able conditions  a  coagulation  necrosis  occasioned  by  the 
interruption  of  circulation.     Thus  these  forms  of  retarded 

6  Crystals  of  haematoidin  (=bilirubin)  were  found  by  Virchow 
as  early  as  1847  (Verhandl.  d.  Oes.  f.  Oeburtsh.  in  Berlin,  vol.  ii) 
in  the  kidneys,  the  tissues,  and  the  blood  of  infants  who  died  while 
suffering  from  icterus  neonatorum.  Their  main  location  is  in 
the  renal  epithelium  and  in  the  uriniferous  tubes,  but  rarely 
in  the  urine.  They  are  also  found  in  the  fibrinous  coagula  of 
the  heat,  in  the  parenchyma  of  the  liver  (Orth),  and  in  the 
adipose  tissue  of  the  omentum  (Neumann).  Even  in  macerated 
foetuses  they  were  met  with  by  Neumann  and  Ruge.  It  appears, 
therefore,  that  at  the  time  of  birth,  and  soon  after,  bilirubin 
exists  in  the  blood  and  tissues  (with  or  without  jaundice)  in  a 
sufficient  quantity  to  permit  its  getting  free  in  crystalline  form 
even  after  death.  The  presence  of  genuine  uric-acid  infarctions 
is  not  influenced  by  this  phenomenon,  and  they  and  bilirubin  may 
occur   simultaneously   or   separately. 

384) 


NEPHRITIS    OF    THE    NEWBORN 

circulation,  to  which  I  alluded  before  in  a  different  connec- 
tion, exert  a  baneful  influence  from  a  chemical  point  of 
view. 

The  normal  frequency  of  uric  acid  and  other  renal  in- 
farctions explains  the  great  many  cases  of  gravel  and  stone 
in  the  very  young.  They  are  observed  in  the  earliest  age, 
contrary  to  the  opinion  of  Rosenstein.  This  great  author 
on  the  diseases  of  the  kidneys  repudiates  the  connection 
between  the  symptoms  of  renal  colic  and  vesical  calculi, 
and  between  renal  infarctions  and  vesical  calculi.  He 
admits  having  observed  renal  colic  in  the  first  year  of  life, 
but  in  a  single  baby  only.  Now  this  is  very  unfortunate, 
and  can  be  explained  only,  I  believe,  by  some  characteris- 
tics in  the  field  of  his  observations.  Exceptional  cases, 
such  as  those  of  Woehler  and  Denis,  in  which  a  renal  calcu- 
lus consisting  of  uric  acid  was  found  in  a  premature  and 
stillborn  fa?tus,  need  not  be  counted  at  all.  But  the  ob- 
servations of  Heusinger  relating  to  the  frequent  occurrence 
of  renal  calculus  in  the  first  year  of  life  are  more  conclusive. 
I  met  with  renal  calculus  quite  frequently  when  I  had  more 
opportunities  to  make  autopsies  of  young  infants,  and  have 
often  alluded  to  a  series  of  forty  post-mortem  examinations 
made  on  babies  who  died  of  miscellaneous  diseases,  in  six 
of  whom  I  found  a  renal  calculus.  Nor  do  I  believe  I  am 
mistaken  when  I  express  my  conviction  that  many  of  you 
have  observed  actual  gravel  in  the  very  young,  and  many 
more  the  violent  spasmodic  pains  of  infants,  accompanied 
with  erections,  dysuria,  even  convulsions,  and  sudden  relief 
mostly  attended  with  urination. 

It  is  evident  that  the  presence  of  crystalline  masses  in 
the  tubes  and  papillae  of  the  kidneys  is  liable  to  be  danger- 
ous. They  encroach  upon  the  soft  tissue  in  which  they 
are  imbedded,  disintegrate  the  epithelium,  irritate  the  sur- 
face, and  produce  slight  haemorrhage  and  inflammation.  In 
many  cases  of  nephritis  of  the  very  young  there  was  a  dis- 
tinct history  of  dysuria  and  of  copious  deposits  in  the  nap- 
kins, not  infrequently  mixed  with  blood.  What  gravel  and 
stone  can  accomplish  in  more  advanced  months  and  years 
is  more  easily  brought  about  in  the  half -perfected  tissue  of 
the  newborn. 

385 


DR.    JACOBI'S    WORKS 

In  regard  to  the  dangers  attending  the  presence  of  uric 
acid  in  the  kidneys  I  have  more  to  say  on  preventives  than 
curatives.  When  we  deal  with  gravel  and  stone  in  the 
kidneys  of  adults  our  efforts  are  directed  to  the  solution  of 
the  deposits.  Plenty  of  water,  alkaline  mineral  waters^ 
alkalies,  mainly  potassic  salts,  lithia,  piperazine,  arid  lysi- 
dine  are  pressed  into  service.  In  the  newborn,  in  whom  we 
must,  as  infarctions  are  the  rule,  except  the  presence  of  the 
danger,  we  are  in  the  habit  of  doing  absolutely  nothing, 
though  prevention  be  within  easy  reach.  Water  is,  if  not 
the  panacea,  at  all  events  the  indicated  remedy.  But  in  no 
period  of  life  is  water  more  withheld  from  the  helpless 
creature  than  in  the  first  few  days.  Mother's  milk  is  not 
forthcoming  until  a  few  days  have  passed  by,  and  then  it 
appears  in  small  quantities  only.  Even  the  experience  that 
the  newborn  lose  weight  by  being  starved  is  charged 
against  Providence,  which  has  willed  it  so  from  times  ante- 
diluvial.  If  water  were  given  plentiful  and  as  methodically 
as  syrup  of  figs  or  castor  oil,  much  harm  could  be  avoided. 
And  here  permit  me  a  few  words  pro  domo.  In  regard  to 
feeding  the  newborn,  I  have  practised  these  forty  years, 
and  taught  thirty-five,  not  only  that  the  very  young  infant 
must  be  fed,  but  that  its  artificial  food  must  be  greatly 
diluted.  In  those  early  times  I  knew  only  that  the  baby 
would  best  bear  great  dilutions,  and  I  mixed  a  part  of  boiled 
milk  with  four  or  five  parts  of  water,  or  rather  of  a  thin 
cereal  decoction.  The  latter  have  at  last  been  recognized 
as  correct,  even  by  Heubner,  whose  main  labors  for  years 
have  been  spent  on  studying  and  discussing  the  question 
of  artificial  infant  food.  But  he  still  sets  his  face  against 
what  he  calls  "  Jacobi's  exorbitant  dilutions."  In  the  light 
of  what  I  have  had  the  honor  of  saying  to-night,  I  profess 
to  have  even  in  those  remote  times  taught  better  than  I 
knew.  At  those  times  I  considered  the  question  of  digestion 
only  when  I  recommended  large  dilutions.  It  is  only  a 
dozen  years  ago,  perhaps,  that  I  began  to  consider  the  ques- 
tion of  high  dilution  of  the  food  of  the  newborn  from  the 
point  of  view  of  its  beneficence  in  renal  infarction  and  its 
consequences.   In  1887  I  spoke  of  its  indication  for  the  pur- 

386 


NEPHRITIS    OF    THE    NEWBORN 

pose  of  dissolving  and  eliminating  uric-acid  infarctions  in 
my  Intestinal  Diseases  of  Infancy  and  Childhood.  I  can 
assure,  as  I  said  then,  that  since  my  advice  of  greatly  dilut- 
ing the  food  of  the  newborn,  and  giving  plenty  of  water 
from  the  beginning,  has  commenced  to  be  minded,  I  am 
sadly  deprived  of  the  many  cases  of  gravel,  dysuria,  shriek- 
ing spells,  and  consecutive  nephritis  which  were  so  common 
in  former  times. 

The  connection  of  icterus  of  the  newborn  with  local 
changes  in  the  kidneys  is  of  vital  interest.  In  the  adult 
this  intimate  dependency  upon  each  other  is  rare,  though 
many  gross  anatomical  changes  are  equally  found  in  all 
ages.  To  that  class  belong  septic  infection,  syphilis  of  the 
liver,  cirrhosis  of  the  liver  of  whatever  origin,  obliterations 
of  the  biliary  ducts,  thrombosis  of  the  portal  vein,  and 
catarrh  of  the  duodenum  and  choledochus  duct. 

In  the  newborn  many  undoubted  cases  of  icterus  are 
due  to  the  destruction  of  red  blood-cells  in  the  first  few 
days,  and  to  the  transformation  of  haematin  into  haematoidin 
(identical  with  bilirubin).  Some  of  the  latter  comes  from 
the  many  ecchymoses  and  stagnations,  both  in  the  skin  and 
the  subcutaneous  tissue,  due  to  the  process  of  parturition. 

The  destruction  of  blood-cells  in  the  newborn  is  a 
normal  occurrence.  According  to  Hayem  and  Helot  the 
blood-cells  of  the  newborn  are  subject  to  rapid  disinte- 
gration. According  to  Hofmeier  the  normal  congregation 
of  the  blood-cells  is  absent;  they  exhibit  a  greater  resist- 
ance to  salving  liquids;  the  number  of  leucocytes  is  very 
changeable,  and  the  size  of  the  blood-corpuscles  is  very 
variable.  Silbermann  found  many  blood-cells  pale,  others 
of  normal  color  in  their  periphery  only;  many  of  various 
sizes — macro-  and  microcytes.  He  also  met  with  nucleated 
blood-cells  in  the  liver,  the  spleen,  and  the  bone  marrow; 
with  cells  of  the  liver,  sometimes  also  of  the  spleen,  and  of 
the  bone  marrow  containing  blood;  with  red  bodies  of  the 
club  and  biscuit  form,  evidently  changed  blood-cells ;  and 
finally  an  increase  of  leucocytes.  All  of  these  observations 
appear  to  prove  the  destructibility  of  the  blood  of  the  new- 
born, which  is   only   equaled,  or  perhaps   even   surpassed, 

387 


DR.    JACOBFS    WORKS 

by  the  effect  of  chronic  poisoning,  in  part  observed  for 
experimental  purposes.^ 

By  many  the  jaundice  of  the  newborn  is  attributed 
to  absorption  of  bile  into  the  blood  directly  from  the  bil- 
iary ducts  into  the  small  vessels  of  hepatic  circulation. 
By  others  a  congenital  narrowness  of  the  choledochus  duct 
or  an  accumulation  of  mucus  in  the  biliary  ducts,  or  (cdcma 
of  the  periportal  connective  tissue,  or  venous  obstruction  in 
the  liver  and'  consecutive  compression  of  biliary  ducts 
were  claimed  as  the  causes  of  jaundice.  Quincke  ex- 
plained it  by  the  patency  of  the  ductus  venosus  Arantii, 
and  by  absorption  of  bile  from  the  meconium  of  the  intes- 
tines. 

Meconium  is  rich  in  bilirubin.  The  latter  is  stored  in 
it  during  and  after  the  third  month  of  intra-uterine  life. 
Biliverdin  accompanies  it  to  such  a  large  amount  that 
Simon  (Arch.  f.  Gyndh.,  1875)  met  with  four  per  cent, 
of  it. 

This  bilirubin  and  biliverdin  are  very  liable  to  be  ab- 
sorbed through  the  open  ductus  venosus  Arantii,  which  re- 
mains patent  in  seventy-seven  per  cent,  of  all  the  new- 
born until  after  the  first  week  of  their  lives.  Its  circula- 
tion is  free,  its  blood  liquid,  and  there  is  a  direct  communi- 
cation from  the  intestinal  circulation  with  that  of  the  vena 


7  Toluylendiamine,  according  to  Afanassiew  and  Stadelman, 
exhibits  the  following  results:  Dissolution  of  red  blood-corpuscles 
and  consecutive  haemoglobinuria ;  increase  of  the  coloring  matter 
of  the  bile;  anaemia;  moderate  fatty  degeneration  of  the  large 
glands;  acute  parenchymatous  nephritis;  destruction  of  renal 
epithelia.  At  the  same  time  the  epithelia  of  the  spleen  and 
liver  are  seriously  damaged  either  directly  by  the  (experimental) 
poison  or  by  the  circulation  of  an  altered  blood.  The  urine  con- 
tains copious  conglomerate  crystals,  which  probably  are  not 
organic,  but  consist  of  calcium  sulphate. 

8  Some  communication  of  the  same  kind,  with  the  same  effect, 
is  brought  about  between  the  haemorrhoidal  plexus  of  the  rectum 
(through  the  haemorrhoidal  vein)  and  the  vena  cava,  thus  cir- 
cumventing the  liver.  Still,  it  must  be  remembered  that  less 
absorption   takes  place   in   the   rectum   than   in   the   rest   of  the 

388 


NEPHRITIS    OF    THE    NEWBORN 

Through  the  open  ductus  venosus  Arantii  the  coloring 
matter  of  the  bile  enters  the  circulation  of  the  whole  body, 
circumventing  the  liver  to  such  an  extent  that  in  some 
cases  of  icteric  newborn  infants  it  does  not  participate  in 
the  jaundice  at  all,  and  produces  different  degrees  of  ic- 
terus. When  peristalsis  is  active,  circulation  and  absorption 
are  so  in  proportion,  and  icterus  is  early;  when  peristalsis 
is  but  sluggish,  and  meconium  retained  unusually  long, 
icterus  may  appear  at  a  late  period.  In  premature  babies 
the  ductus  venosus  is  large,  and  jaundice  liable  to  be  early 
and  very  intense.  When  Elsasser,  however,  found  it  closed 
in  three  cases  no  jaundice  was  observed.  Immediately 
after  birth  the  coloring  matter  of  the  bile  is  considerably 
increased,  and  therefrom  results  another  additional  cause 
of  jaundice.  Besides,  as  it  has  been  stated,  there  is  no 
period  of  life  in  which  under  normal  circumstances  so 
many  blood-cells  undergo  rapid  disintegration.  Therein 
lies  another  cause  for  the  formation  of  bilirubin,  and  for 
a  direct  thrombotic  interruption  of  circulation  in  the  small- 
est blood  vessels.  Finally,  there  is  no  period  of  life  when 
elimination  is  less  active  than  during  the  first  days  of  life. 
At  that  time  the  urine  is  very  scanty,  the  water  supply 
mostly  neglected,  and  the  accumulation  of  effete  material 
the  rule. 

Moreover,  bilirubin  is  but  scantily  dissolved  in  the  fluids 
of  the  tissues  of  the  newborn;  even  in  strongly  alkaline 
solutions  it  is  but  slightly  soluble,  according  to  Hoppe- 
Seiler.  Thus  it  is  that  the  coloring  matter  of  bile  is  met 
with  in  the  urine  of  the  newborn  in  the  shape  of  the 
yellow  masses  (masses  jaunes)  which  have  already  been 
mentioned  in  connection  with  urinary  infarctions. 

When  the  absorbed  and  deposited  masses  are  but  scanty 
they  may  be  eliminated  without  any  symptoms.  When 
there   is   enough   of   them   to    result   in    a   local  irritation, 

intestinal  tract.  Absorption  is  very  much  more  active  in  the 
upper  part  of  the  large  intestine.  Kiihne  knew,  1868  (Physiol. 
Chem.),  that  icterus  may  originate  in  absorption  from  the  colon; 
and  in  the  small  intestines  both  the  amount  of  meconium  and 
the  absorbability  of  its  bilirubin  and  biliverdin  are  much  greater. 

389 


DR.    JACOBI'S    WORKS 

they  will  cause  albuminuria^  which  is  often  found  in  ill- 
nourished  icteric  babies.  When  there  is  enough  to  cause 
thromboses,  which  are  quite  common  in  the  capillaries  of 
the  portal  system,  and  obstruction  of  circulation,  they 
give  rise  to  haemorrhages  or  to  inflammation.  As  far  as 
the  kidneys  are  concerned,  there  is  a  peculiar  anatomical 
reason  why  nephritis  is  very  liable  to  appear  in  the  very 
young. 

The  post-foetal  growth  of  blood-vessels  and  tissues 
varies  considerably.  It  is  least  in  the  common  carotid, 
largest  in  the  renal  and  femoral  arteries.  The  renal  artery 
and  the  kidneys,  however,  do  not  develop  proportionately; 
the  transverse  section  of  the  former  increases  out  of  pro- 
portion to  the  volume  and  weight  of  the  latter.  Thus  it 
seems  that  this  disproportion  between  the  size  of  the 
artery  and  the  condition  of  the  renal  tissue  establishes  a 
predisposition  to  congestive  and  inflammatory  conditions  of 
the  organ.  Moreover,  the  resistance  in  the  capillary  net  of 
the  young  kidney  is  unusually  great.  Experiments  prove 
that  the  permeability  of  the  capillaries  is  greater,  and  that 
within  a  given  time  a  proportionately  larger  amount  of 
water  can  be  squeezed  through  them  in  the  adult  than  in 
the  young.  This  anatomical  diff"erence  seems,  therefore,  to 
be  an  additional  reason  why  renal  diseases  are  so  much 
more  frequent  in  infancy  and  childhood,  from  all  causes, 
with  the  only  exception  of  that  which  is  reserved  for  the 
very  last  decades  of  natural  life — viz.,  atheromatous  de- 
generation.* 

In  conclusion,  Mr.  President,  permit  me  to  recapitulate 
in  a  few  words  the  main  points  of  this  paper: 

Nephritis  is  a  frequent  disease  of  infancy  and  child- 
hood and  by  no  means  very  rare  in  the  newborn.  What 
was  formerly  considered  mere  albuminuria,  or  a  transient 
form  of  it,  we  have  been  taught  by  improved  methods  of 
investigation,  mainly  by  the  use  of  the  centrifuge,  to  recog- 
nize as  nephritis.  A  predisposition  to  nephritis  in  the 
young  is  caused  by  the  fragility  of  the  blood-vessels  in  the 

»  Heart  and  Blood-vessels  in  the  Young.  By  A.  Jacobi,  M.  D., 
Brooklyn  Med.  Jour.,  March,  1888. 


NEPHRITIS    OF    THE    NEWBORN 

newborn;  by  the  relative  imperviousness  of  the  young 
renal  capillaries  compared  with  the  large  size  of  the  renal 
arteries ;  by  the  feebleness  of  the  young  intestinal  muscle, 
which  proves  insufficient  to  expel  toxic  contents ;  by  the 
extensiveness  and  size  of  the  young  intestinal  blood-vessels 
and  lymphatics  and  the  large  size  of  the  villi,  all  of  which 
favor  the  absorption  of  toxines. 

From  an  aetiological  point  of  view,  nephritis  in  the  new- 
born may  be: 

1.  Congestive  (from  feeble  circulation,  congenital  heart 
disease,  asphyxia,  or  exposure  to  low  temperatures). 

2.  Obstructive  (from  the  physiological  rapid  decompo- 
sition of  the  blood  of  the  newborn;  the  formation  of 
haematoidin=:bilirubin ;  jaundice;  the  production  of  methae- 
moglobin  by  chemical  poisons,  such  as  potassic  chlorate,  or 
by  excessive  heat;  or  the  presence  of  blood  in  the  urinif- 
erous  tubes). 

3.  Irritative  (from  the  presence  of  uric-acid  infarctions 
or  haematoidin  infarctions,  or  purpuric  or  other  interstitial 
haemorrhages,  or  of  microbes  and  toxines  in  the  numerous 
eruptive  and  infectious  maladies  and  in  enteritis). 


891 


THE  PREVENTION  OF  TUBERCULOSIS  IN 
SCHOOL  CHILDREN 

Ladies  and  Gentlemen: 

Some  weeks  ago  the  Charity  Organization  published  a 
Handbook  on  the  Prevention  of  Tuberculosis.  Among  the 
contributors  to  it  are  some  of  the  most  eminent  physicians 
and  authors  of  New  York.  Thus  its  statements  may  well 
be  accepted  as  authoritative.  Indeed,  I  know  of  no  volume 
which  will  communicate  the  same  information  on  the  sub- 
ject of  tuberculosis  in  as  concise,  handy,  and  skilful  a 
manner.  While  commending  its  perusal  to  all  my  hearers, 
I  know  I  cannot  add  to  its  wealth  of  ideas  and  its  store- 
house of  truths.  What  is  left  for  me,  therefore,  is  to  apply 
many  of  the  facts  to  a  special  topic,  namely,  the  problem 
of  tuberculosis  in  connection  with  school  teachers  and 
pupils. 

I  do  not  feel  certain  that  there  are  not  many  here  who 
are  well  acquainted  with  some  or  most  of  what  I  shall 
have  to  say,  for  tuberculosis  has  for  years  been  the  sub- 
ject of  discussion,  in  lectures,  societies,  magazines,  and 
newspapers.  Some  part  of  the  subject  is  known  to  every- 
body. What  we  call  consumption,  that  is,  tuberculosis  of 
the  lungs  with  formation  of  abscesses  and  the  usual  or 
frequent  termination  of  the  disease  in  death,  is  of  daily 
occurrence  and  many  of  you  have  met  it  amongst  your 
friends  and  relatives.  If  statistics  do  not  lie,  there  is  no 
large  company  that  does  not  harbor  candidates  or  victims 
of  the  malady  in  some  form  or  another.  Is  there  anything 
that  should  be  studied  with  greater  persistency  by  those 
who,  like  you,  are  stationed  between  science  and  its  ap- 
plication, and  who  have  more  ample  opportunity  to  dis- 
seminate useful  knowledge  than  most  other  professional 
people?  Nor  should  the  knowledge  of  the  teacher  be 
superficial.  Only  what  is  thoroughly  understood  can  be 
applied  or  taught  in  plain  words ;  and  plain  language  is 

393 


DR.    JACOBFS    WORKS 

required  when  you  mean  to  instruct  a  child,  and  through 
the  child,  its  family.  You  have  or  will  have  to  deal  with 
the  young  at  a  time  when  his  mind  is  most  receptive  and 
his  tongue  most  communicative.  That  is  why  a  number  of 
plain  rules  are  readily  grasped  and  understood  by  a  child, 
and  the  child  taught  by  you  may  prove  a  teacher  at  home 
for  his  father  and  mother,  who  have  not  the  time  to  read, 
though  some  of  them  may  have  more  literary  material  than 
mere  sensational  newspaper  gossip.  In  this  way  the  knowl- 
edge of  the  nature  and  the  prevention  of  tuberculosis  may 
become  disseminated,  and  the  disposition  to  the  dread 
scourge  may  be  recognized  and  gradually  extinguished. 

Every  educated  person,  certainly  every  one  of  you,  knows 
perfectly  well  that  tuberculosis  is  the  direct  result  of  the 
presence  in  large  numbers  of  a  minute  microbe,  the  bacillus 
of  tuberculosis,  or  its  toxin  (or  virus)  in  the  body  of  the 
patient.  Its  influence  need  not  be  immediate.  It  may  be 
buried  away  in  some  part  of  the  organism  for  a  long  time 
waiting  for  its  chance.  That  chance  will  come  when  some 
other  disease,  particularly  one  of  an  inflammatory  character, 
breaks  out,  or  when  such  microbes  as  are  the  cause  of  or 
connected  with  suppuration,  in  small  or  large  abscesses, 
combine  their  forces  with  those  of  the  bacillus.  In  such 
a  case  the  outbreak  is  apt  to  be  a  very  sudden  one  and 
we  have  an  instance  of  so-called  acute  tuberculosis  or  rapid, 
or  florid,  or  hasty  consumption. 

Of  the  location  and  the  frequency  of  tuberculosis  in  the 
very  young  I  spoke  a  year  ago  at  another  place.  In  the 
infant  and  the  very  young  child,  where  you  personally  have 
few  opportunities  of  close  observation,  tuberculosis  may  be 
found  as  a  chronic  disease,  in  the  end  of  a  bone,  or  in  a 
gland;  also  in  the  pleura  and  peritoneum;  in  its  acute  state 
mostly  in  the  brain  and  a  nunjber  of  other  organs  where  it 
is  almost  invariably  fatal.  In  your  profession  you  have  to 
deal  with  children  after  the  sixth  or  seventh  years  and  with 
adolescents,  in  whom  tuberculosis  is  very  apt  to  follow  the 
same  course  and  exhibit  the  same  symptoms  which  are  met 
in  the  adult.  Here  you  find  it  mostly  in  the  lungs.  In  not 
a  few  cases  tuberculosis  may  be  easily  recognized,  or  at 
least  suspected.     When  you  have  to  deal  with  a  child  that 


PREVENTION    OF    TUBERCULOSIS 

is  unusually  pale,  or  of  low  weight,  easily  exhausted,  with 
glandular  swelling  about  the  neck  and  narrow  chest,  tuber- 
culosis should  be  suspected  and  proper  care  should  be  taken, 
for  it  should  never  be  forgotten  that  tuberculosis  may  heal 
or  be  made  to  heal. 

As  a  modification,  or  as  suspicious  or  incipient  symptoms, 
you  will  not  infrequently  notice  the  symptoms  of  what  has 
been  called  scrofula.  Scrofula  is  observed  in  two  forms. 
There  are  a  number  of  children,  usually  brunettes,  with  dark 
hair,  florid  cheeks,  brilliant  eyes,  low  weight,  quite  fre- 
quently with  good  mental  capacity,  who  display  diseases  of 
the  mucous  membranes ;  their  eyes  are  frequently  sore,  some 
of  the  glands  of  the  neck,  perhaps  many,  are  considerably 
swollen.  The  other  form  of  scrofula  is  a  more  sluggish 
or  torpid  one.  The  children  are  rather  heavy,  flabby,  mostly 
pale,  with  large  and  rather  hanging  cheeks,  and  big  lips, 
and  there  is  swelling  of  the  nose  and  considerable  tume- 
faction of  glands  about  the  neck,  with  not  infrequently 
sore  eyes,  ears,  and  skin.  This  is  the  usual  form,  and  the 
one  which  is  apt  to  lead  into  tuberculosis  during  school 
age.  That  is  why  I  wish  to  direct  your  special  attention 
to  this  form  of  disease.  Of  great  importance  in  connection 
with  it  is  the  presence  of  those  glandular  swellings  round 
the  neck,  and  it  is  to  this  that  I  ask  your  attention  for  a 
few  minutes. 

You  know  that  the  circulation  in  the  animal  body  is  two- 
fold— first,  that  of  the  blood;  second,  that  of  the  lymph. 
The  lymph  is  disseminated  through  the  body  in  every  organ, 
but  particularly  in  and  below  the  mucous  membranes.  The 
absorption  of  chyle  as  furnished  by  digestion  takes  place 
from  millions  of  small  glandular  bodies,  many  of  them  of 
microscopic  size  only.  They  are  disseminated  over  the  intes- 
tinal mucous  membranes,  whose  contents  they  absorb  and 
carry  off"  into  larger  vessels,  and  from  them  into  lymph 
bodies  or  so-called  glands  of  the  mesentery,  in  the  im- 
mediate neighborhood  of  the  intestines.  They  are  very 
numerous  all  over.  From  them  the  current  goes  on  into 
still  larger  vessels  until  finally  they  terminate  in  a  large 
duct,  the  thoracic  duct,  which  discharges  its  contents  into 
the  circulation  of  the  blood.     That  circulation  in  the  lymph 

S95 


DR.    JACOBFS   WORKS 

is  very  extensive  and  copious.  It  has  been  found  that  an 
artificial  opening  made  into  the  thoracic  duct  of  a  young 
dog  furnished  lymph  to  tlie  amount  of  between  one-sixth 
and  one-tenth  of  the  weight  of  that  dog  within  one  day, 
while  an  adult  dog  furnished  lymph  amounting  to  only 
one-tenth  to  one-sixteenth  of  the  body  weight.  In  the  same 
way  the  lymph  apparatus  in  a  young  child  up  to  advanced 
childhood  and  adolescence  is  very  much  more  active  than  it 
is  in  the  adult. 

That  is  why  the  condition  of  the  lymph  glands  in  the 
young  is  of  such  importance.  Whenever  there  is  any  in- 
fection of  the  mucous  membrane,  the  infecting  poison  is 
carried  off  to  the  next  gland  where  there  is  a  stopping- 
place.  That  gland  will  become  the  seat  of  irritation  or 
swelling.  That  is  why — to  give  you  an  example — when- 
ever there  is  only  a  slight  diarrhoea,  no-  matter  from  what 
cause,  over-eating,  improper  food,  medicines,  typhoid,  colds 
— never  from  dentition,  for  there  is  no  such  thing  as  diar- 
rhoea from  teething  in  a  healthy  child — the  lymph  bodies 
in  the  neighborhood  will  swell.  Unless  such  a  diarrhoea 
is  soon  stopped  the  irritation  will  continue,  congestion,  in- 
flammation, and  swelling  of  the  glands  will  ensue,  and  the 
structure  of  these  neighboring  glands  will  be  changed. 
When  such  an  inflammation  of  the  gland  has  lasted  a  long 
time  and  new  tissue  has  been  formed  in  it,  it  may  or  will 
remain  unchanged  and  unalterable,  no  matter  what  you  may 
do  for  it. 

The  same  takes  place  about  the  lungs.  Whenever  a  baby 
or  adult  has  catarrh  with  some  cough  and  mucous  expector- 
ation, the  neighboring  glands  in  the  chest — bronchial  or 
mediastinal — will  swell,  and  unless  such  catarrh  is  broken 
up  the  swelling  may  go  on  until  the  glands  are  hardened 
or  undergo  other  changes.  Sometimes  they  will  form  ab- 
scesses and  break  up.  Whenever  there  is  in  a  child  or  in 
an  adult,  particularly  in  the  young  of  the  age  with  which 
you  have  to  deal,  a  catarrh  of  the  nasal  mucous  membrane, 
the  glands  about  the  neck  will  immediately  swell.  This 
swelling  will  pass  off  when  the  nasal  catarrh  passes  off". 
When  it  lasts  long,  when  it  becomes  a  chronic  catarrh,  the 
swelling  of  the  glands  remains ;  they  become  hardened,  they 

396 


PREVENTION  OF  TUBERCULOSIS 

are  no  longer  amenable  to  the  effect  of  medicine  or  to  ex- 
ternal treatment;  they  may  finally  break  down  and  form 
abscesses.  While  they  are  in  this  swelled  condition  the 
lymph  current  through  them  will  be  interrupted,  and  what- 
ever is  floating  in  it  will  there  be  caught  and  infect  the 
gland.  Moreover,  the  minute  capillary  blood  vessels  are 
smaller  in  the  glands  than  elsewhere,  and  microbes  which 
are  easily  passed  by  capillaries  elsewhere  and  finally 
thrown  out  of  the  system  will  be  caught  in  the  capillaries 
of  the  glands.  In  this  way  the  glands  around  the  neck, 
that  were  not  primarily  infected  by  disease-producing 
germs,  may  become  the  receptacles  of  disease.  They  may 
become  tubercular  when  tubercle  bacilli  are  floating  in  the 
general  circulation  (although  they  might  have  been  carried 
ofi'  if  the  organs  had  been  healthy),  and  be  caught  in  the 
slow  circulation  of  the  gland  and  there  remain.  From  there 
the  invasion  of  the  whole  body  may  take  place.  Thus  you 
see  that,  often  in  a  healthy  family  or  in  an  otherwise 
healthy  child,  a  nasal  catarrh  of  some  duration  may  furnish 
the  first  inroad  of  tubercular  bacilli.  This  is  particularly 
so  in  infectious  diseases  which  affect  the  mucous  membrane 
to  a  high  degree — for  instance,  in  measles  or  whooping 
cough.  Measles  and  whooping  cough  are  often  the  fore- 
runners of  tuberculosis. 

As  long  as  the  mucous  membranes  are  in  a  healthy  con- 
dition they  may  be  covered  with  no  end  of  foreign  material, 
microbes  included,  with  no  danger  to  the  individual  whatso- 
ever. There  are,  for  instance,  very  few  probably  among  us 
here  that  do  not  carry  either  bacilli  of  tuberculosis  or  bacilli 
of  diphtheria  in  their  noses  and  throats  this  very  moment. 
As  long  as  our  mucous  membranes  are  in  a  healthy  condition 
the  microbes  will  not  be  absorbed.  As  soon,  however,  as 
the  membranes  are  no  longer  in  that  healthy  condition, 
when  the  microscopical  epithelia  that  cover  the  membrane 
are  destroyed  or  altered  or  washed  off,  then  those  foreign 
guests,  innocent  up  to  that  time,  will  creep  into  the  sore 
tissues  and  the  whole  system  will  become  affected.  Thus 
it  may  even  be  that  a  healthy  person,  harboring  the  bacilli 
of  diphtheria  or  tuberculosis,  may  infect  other  people 
though  he  has  not  been  infected  himself. 

897 


DR.    JACOBI'S    WORKS 

The  infection  of  the  glands  of  the  neck  does  not  depend 
on  a  morbid  condition  of  the  mucous  membrane  of  the  nose 
alone;  the  vast  area  of  the  mucous  membrane  extending 
down  to  the  pharynx  and  upward  to  the  nose  may  be  af- 
fected. There  is  no  mucous  surface  that  is  covered  and 
penetrated  with  small  lymph  bodies  to  such  an  extent  as 
that  of  these  organs.  The  lymph  bodies  in  the  hind  part 
of  the  nose  form,  when  they  grow,  what  has  been  called 
adenoids.  They  sometimes  reach  such  a  size  as  to  obstruct 
nasal  respiration,  compel  the  patient  to  have  the  mouth 
open  to  breathe,  and  cause  him  to  hear  and  to  sleep  with 
open  mouth,  increasing  the  danger  of  infection  on  account 
of  the  wide  access  given  to  microbes  floating  in  the  air. 
In  that  condition  the  night  is  the  most  dangerous  time. 
Adenoids  and  the  whole  mucous  membrane  have  frequently 
been  found  to  be  covered  with  tubercular  bacilli,  more  so 
than  perhaps  the  tonsils. 

When  the  bacilli  are  absorbed,  their  next  lodging-place 
is,  as  I  said,  the  neighboring  glands.  These  glands  about 
the  neck  form  three  tiers  all  the  way  down  to  the  clavicle. 
From  there  the  lymph  current  goes  downward  into  the 
chest  and  into  the  axilla;  thus  the  lymph  bodies  or  so-called 
glands  swell  in  the  axilla  and  in  the  chest.  These  lymph 
bodies  in  the  chest  are  in  direct  contact  with  the  mucous 
membrane  of  the  large  wind-pipes,  and  in  that  way  with 
the  smaller  wind-pipes  and  with  the  lungs.  That  is  quite 
frequently  the  way  in  which  bacilli  and  other  virus  enter 
the  lungs.  It  is  often  the  process  in  the  adult  and  in  the 
adolescent  and  in  the  growing  child. 

When  you  understand  that,  you  see  how  important  it  is 
that  the  mucous  membrane  of  the  nose  and  of  the  mouth 
should  be  taken  care  of  in  the  very  young  and  in  the  grow- 
ing child.  A  great  many  cases  of  tuberculosis,  diphtheria, 
and  other  contagious  and  infectious  diseases  could  be  pre- 
vented if  there  were  no  diseased  mucous  membrane  greedy 
after  infecting  material.  That  is  why  it  should  be  a  rule 
in  every  family  where  there  is  the  slightest  tendency  to 
nasal  and  throat  catarrh  to  irrigate  the  nose  and  the  throat 
at  least  once  a  day,  better  twice  a  day,  with  warm  water  in 
which  a  very  small  dose  of  common  table  salt  is  dissolved. 

398 


PREVENTION  OF  TUBERCULOSIS 

This  so-called  saline  solution  contains  from  six  to  seven 
parts  of  salt  to  one  thousand  of  water.  A  good  proportion 
for  practical  purposes  is  half  a  teaspoonful  of  table  salt 
to  a  good  tumblerful  of  warm  water.  Part  of  this  should 
be  filled  into  a  common  nasal  cup,  the  head  should  be 
thrown  back,  and  small  quantities  should  be  allowed  to 
run  down  the  nose  into  the  throat.  If  it  be  swallowed 
there  is  no  harm,  but  children  will  learn  very  rapidly  how 
to  bring  up  the  salt  water.  In  this  way  the  mucous  mem- 
branes are  kept  intact,  and  nobody  can  tell  how  many 
diseases  are  kept  away  by  this  very  simple  method.  I 
can  prove  that  it  does  have  that  effect,  for  you  will  in- 
variably notice  that  whenever  you  have  a  catarrh  of  the 
nose,  or  even  when  you  see  a  very  severe  case  of  diphtheria 
of  the  nose  (one  of  the  most  dangerous  forms  of  that 
disease),  the  large  swellings  of  the  neck  will  be  reduced 
in  a  very  short  time  by  doing  nothing  whatever  except  fol- 
lowing the  rules  just  laid  down.  No  medicine,  no  iodine, 
no  mercury  is  required,  simply  the  washing  out — in  an 
acute  disease  like  diphtheria  very  often — every  one  or 
two  hours.  In  common  nasal  catarrh,  twice  a  day  is  suffi- 
cient to  reduce  from  day  to  day,  or  even  from  hour  to 
hour,  the  size  of  the  glands,  unless  it  have  lasted  weeks 
or  months.  Sometimes,  even  when  it  has  lasted  weeks,  and 
not  infrequently  when  it  has  lasted  months,  the  correct 
irrigation  of  the  nose  twice  or  three  times  a  day  will  grad- 
ually, within  a  few  weeks  or  a  month,  not  only  reduce,  but 
remove,  the  swelling  that  had  been  annoying  for  many 
months  or  even  a  year.  In  this  connection  I  may  say  that 
nothing  but  irrigations  should  be  used  under  ordinary  cir- 
cumstances, and  no  injections.  No  syringes  should  be  used 
unless  ordered  by  the  physician  in  very  bad  cases  of  diph- 
theria, where  it  is  important  to  remove  a  great  many  of 
the  accumulated  membranes  in  as  short  a  time  as  possible. 
I  will  add,  too,  as  a  practical  rule,  that  sprays,  which  are 
so  frequently  used,  are  not  so  effective  either  in  disease  or 
in  comparative  health.  The  washing  out  of  the  nose  can 
be  better  accomplished  by  irrigations  than  by  merely  spray- 
ing. 

What  I  have  thus  far  said  would  settle  in  your  mind  the 

899 


DR.    JACOBFS    WORKS 

question  whether  scrofula  and  tuberculosis  are  identical. 
They  are  not  identical,  but  they  may  become  so.  Imagine 
the  original  catarrh  of  the  nose  and  throat,  brought  on  by 
exposure,  a  drenching  rain,  cold  feet,  drafts  in  a  trolley 
car,  exposure  of  the  perspiring  skin,  met  with  bacilli  which 
had  been  innocent  tenants  on  the  mucous  membrane;  then 
these  tenants  of  the  surface  would  enter  through  the  open 
door,  and  a  real  infection  would  take  place.  In  that  case, 
not  otherwise,  the  scrofula  or  the  alleged  scrofula  of  the 
glands  would  turn  out  to  be  tuberculosis.  Thus  wherever 
there  are  swelled  glands,  wherever  there  is  "  scrofula," 
there  is  not  necessarily  at  the  same  time  tuberculosis,  but 
there  is  danger  of  tubercular  invasion.  Scrofula,  when 
fully  developed  in  a  child,  as  observed  by  you,  will  show  a 
number  of  symptoms  that  are  not  found,  as  a  rule,  in 
tuberculosis.  You  have  sore  eyes,  sore  ears,  swollen  lips, 
and  nose;  you  have  the  glands,  you  have  the  eczema  of  the 
skin ;  if  all  that  were  always  tuberculosis  there  would  be 
no  possibility  of  recovery.  The  scrofulous  disposition  is 
widespread;  it  extends  over  the  skin,  over  the  mucous  mem- 
brane, and  may  show  itself  even  in  the  bones ;  it  is  char- 
acterized by  the  fact  that  whenever  there  is  such  an  in- 
fection, whenever  there  is  scrofulous  irritation  at  least,  it 
is  not  apt  to  heal.  Scrofulous  inflammation  and  ulceration 
are  very  obstinate.  If  all  that  were  tuberculosis  the  patient 
would  be  doomed;  but  tuberculosis  invades  the  body  pri- 
marily in  a  certain  limited  locality.  It  may  remain  in  that 
locality;  it  may  remain  in  the  end  of  a  bone,  in  a  number 
of  glands,  in  a  small  part  of  the  lung,  and  there  may  heal 
up.  In  the  beginning,  therefore,  scrofula  is  a  widespread 
general  "disorder  and  in  the  beginning  tuberculosis  is  a 
local  disease.  That  is  why  on  the  autopsy  table  we  fre- 
quently find  tuberculosis  in  a  body  where  it  was  not  sus- 
pected at  all.  We  find  deposits,  small  or  large  nodules, 
particularly  in  the  upper  part  of  the  lung,  usually  the  right 
lung,  that  are  cases  either  of  dormant  or  of  recovered  tuber- 
culosis. No  such  thing  is  found  in  scrofula.  When  scrof- 
ula heals,  the  whole  body  is  changed  for  the  better.  When 
tuberculosis  heals,  it  is  found  that  it  was  a  local  disease. 
The  invasion  of  tuberculosis  into  the  human  body  may 
take  place  by  inhalation  of  the  bacilli,  or  by  feeding,  with 

400 


PREVENTION  OF  TUBERCULOSIS 

the  exception  of  the  rare  cases  in  which  the  bacilli  get  into 
the  circulation  through  sores  on  the  skin — in  chronic  eczema, 
for  instance — or  through  wounds.  Thus  it  is  that  butchers 
may  contract  tuberculosis  of  the  skin  from  diseased  cattle, 
or  through  an  abscess.  Milk  containing  tubercle  bacilli 
may  infect  the  intestinal  tract,  or  (while  being  swallowed) 
the  lymph  follicles  of  the  throat,  including  the  tonsils, 
and  thereby  on  their  downward  course,  the  body.  From 
either  of  these  places  the  circulation  of  the  blood  or  of 
the  lymph,  mainly  the  latter,  may  be  invaded. 

The  famous  Dr.  Emil  von  Behring,  the  discoverer  or 
rather  inventor  of  the  diphtheria  antitoxin,  proclaims  that 
almost  every  tuberculosis  case,  at  any  age,  originates  in 
the  milk  of  tubercular  cows  taken  by  the  infant  or  child. 
In  most  cases,  in  his  opinion,  tuberculosis  remains  dormant 
for  many  years,  and  every  case  of  tuberculosis  in  an  adult 
is  the  result  of  infection  by  tuberculous  milk,  during  in- 
fancy. That  is  a  cruel  exaggeration.  But  surely  there  are 
many  undoubted  cases  of  feeding  milk  of  tuberculous  cows 
that  resulted  in  tuberculosis.  My  late  friend  Olivier,  of 
Paris,  has  the  following  report:  Thirteen  schoolgirls  in  a 
Paris  boarding-school  were  taken  with  tuberculosis.  Six 
died.  Some  of  them  had  the  disease  first  in  their  bowels. 
The  milk  came  from  a  tuberculous  cow  with  a  badly 
affected  udder.  Johne,  a  great  veterinary  anatomist,  ex- 
amined the  cow  that  had  the  reputation  of  being  the  finest 
on  a  farm  until  she  became  emaciated  and  died.  Indeed, 
on  account  of  her  splendid  condition,  her  milk  had  been 
selected  by  the  farmer  for  his  own  infant.  The  child  died 
of  tuberculosis  at  the  age  of  two  years  and  a  half.  A  case 
like  this  proves,  besides  other  things,  the  correctness  of 
my  teaching  these  more  than  forty  years,  that  it  is  always 
safer  to  select  milk  from  a  herd  of  cows  than  from  a  single 
cow,  thereby  diluting  possible  dangers.  By  experiment  it 
has  been  proven  that  the  milk  of  a  tubercular  cow  when 
mixed  with  forty  times  the  amount  of  healthy  milk  becomes 
devoid  of  dangers. 

But,  after  all,  cases  of  tuberculosis  resulting  from  the  in- 
gestion of  tuberculous  milk  are  rare.  In  the  stomach  bacilli 
do  not  thrive,  and  tuberculous  ulcerations  of  the  intestines 
are  infrequent.      Indeed,  the   abdominal   glands   are   more 

4011 


DR.    JACOBI'S    WORKS 

often  affected  than  the  mucous  membranes  of  the  intestines. 
The  principal  mode  of  entrance  of  tuberculosis  is  that  of 
inhalation,  which  may  be  twofold:  either  that  of  the  dry 
bacilli  contained  in  the  dust  of  the  street,  or  of  a  room 
or  public  place;  or  of  the  moist  particles  of  expectoration 
which  are  thrown  about  in  a  coughing  spell  and  float  in 
the  air  of  a  room  hours  before  they  are  deposited  on  the 
floor.  As  far  as  the  dry  bacilli  are  concerned,  it  may  take 
time  and  some  force  to  remove  them.  A  moderate  air  cur- 
rent is  not  sufficient  for  that  purpose.  Wherever  they  are 
deposited  they  are  waiting  for  their  chance.  Dusting, 
sweeping  of  the  dry  material,  will  fill  the  air  with  bacilli. 
Children's  respiratory  organs,  being  nearer  the  floor  than 
those  of  the  adults,  are  most  exposed.  That  is  why  the 
percentage  of  tubercular  school  children  grows  in  dispro- 
portionate rapidity  with  every  year  of  their  lives. 

Now,  it  may  be  worth  your  while  to  consider  the  final 
location  of  the  inhaled  bacilli;  do  they  reach  the  finest 
ramifications  of  the  bronchial  tubes  and  the  air  cells?  It  is 
not  probable,  for  in  the  advanced  child  and  the  adult  the 
primary  location  of  tuberculosis  is  not  at  all,  or  very  rarely, 
in  these  distant  parts.  It  is  much  more  probable  that 
during  inhalation  the  dangerous  inhalation  is  deposited  in 
the  posterior  part  of  the  nose  and  in  the  throat.  There 
are  those,  however,  who  attribute  to  the  tonsils  the  prin- 
cipal, aye,  even^  the  only  role  in  the  invasion  of  tubercle 
bacilli.  A  late  author  goes  so  far  as  to  build  his  plan 
of  preventing  or  combating  tuberculosis  on  the  total  excision 
of  the  tonsils.  That  is  an  exaggeration.  He  claims  the 
operation  must  be  made  according  to  a  certain  method, 
and,  unfortunately,  he  suggests  that  there  are  but  few  ex- 
cept himself  who  can  perform  it  so  as  to  be  eff'ective. 
Moreover,  it  is  not  true  that  the  tonsil  absorbs  as  readily 
as  the  other  thousand  of  lymph  follicles  of  the  nose  and 
throat.  In  my  studies  on  diphtheria,  before  and  in  1874 
and  in  1880,  I  found  that  when  the  tonsil  alone  was  af- 
fected, the  case  was  a  mild  one,  and  not  accompanied  by 
much  swelling  of  the  neighboring  glands;  that  these  latter 
swelled  principally  when  the  diphtheritic  membrane  reached 
beyond  the  tonsil;  and  that  when  the  mucous  membrane  of 

402 


PREVENTION    OF    TUBERCULOSIS 

the  nose  was  the  seat  of  the  diphtheritic  membrane,  the 
case  was  so  grave  that  before  those  times  and  before  the 
suggestion  of  local  treatment,  every  case  of  nasal  diph- 
theria was  pronounced  fatal  by  a  great  French  authority  of 
that  period,  Roger.  I  showed  that  the  reason  for  the 
relative  innocuousness  of  the  tonsil  is  anatomical.  Though 
its  structure  is  similar  to  that  of  the  smaller  lymph  folli- 
cles disseminated  in  the  neighborhood,  it  is  surrounded  by 
a  firm  fibrous  membrane  which,  to  a  certain  extent,  shields 
the  system  against  a  rapid  absorption  of  poisonous  sub- 
stances which  have  entered  the  tonsils. 

Other  modes  of  entrance  of  bacilli  into  the  system  are 
the  following:  The  finger  nails  of  babies,  like  those  of 
the  adults,  are  unclean.  Though  they  do  not  exhibit  the 
unappetizing  spectacle  of  a  mourning  ring,  they  are  al- 
ways unclean  and  harbor  microbes,  both  uninjurious  and 
injurious.  A  few  years  ago  there  was  a  report  of  a  New 
York  mother  whose  cheek  was  slightly  scratched  by  her 
playful  baby.  The  baby  had  erysipelas  microbes  under  its 
nails,  and  the  mother  died  of  erysipelas.  Thirty  years  ago 
I  lost  a  warm  friend,  a  great  physician,  who,  while  in 
quiet  thought,  scratched  a  small  pimple  on  his  cheek.  His 
erysipelas  originated  in  that  very  spot.  Two  German 
authors  (Preisnitz  and  Schutz)  published  in  1902  their 
observations  on  the  finger  nails  of  children  of  from  six 
months  to  two  years  of  age.  They  proved  that  fourteen 
out  of  sixty-six  had  tubercle  bacilli  under  their  finger  nails. 
No  fixed  star  is  more  immovable  than  the  fact  that  every 
one  of  these  young  ones  had  their  dangerous  pretty  fingers 
in  their  noses  and  mouths.  Now,  tuberculosis  will  rarely 
make  its  appearance  suddenly.  Years  may  pass  before  the 
invalid  lymph  glands  of  the  throat  and  neck  give  up 
their  captive  microbes  and  allow  them  to  travel  downwards. 
That  is  the  time  when  your  pupils  develop  their  tubercu- 
losis, no  matter  whether  they  imported  it  from  the  flying 
dust  of  the  street  or  the  dry  sweeping  of  the  rooms, 
from  their  own  nails,  from  the  crumbs  they  picked  up,  or 
from  their  intimate  comrades,  the  toys. 

Now,  ladies  and  gentlemen,  I  have  repeatedly  spoken  of 
the  fact  that  microbes,  no  matter  in  what  numbers,  may 

403 


DR.    JACOBI'S    WORKS 

invade  the  nose  and  throat  and  are  devoid  of  danger  as 
long  as  the  mucous  membrane  covered  by  them  is  healthy, 
but  that  they  prove,  or  may  prove,  dangerous  when  a 
catarrh  destroys  the  fine  film  of  epithelia  which  protects 
the  surface.  That  is  why  a  cold  is  alwa}^s  enumerated 
amongst  the  causes  of  tuberculosis,  of  diphtheria,  of  rheu- 
matism, even  of  erysipelas  or  of  scarlatina.  As  practical 
people  and  bent  upon  caring  for  yourselves  and  others, 
you  will  ask  me  for  the  methods  of  keeping  the  mucous 
membranes  in  a  sound  condition,  and  thus  preventing  dis- 
ease. That  can  be  done  by  attending  to  the  general  health, 
and  mainly  by  the  hardening  process. 

Much  has  been  said  about  hardening.  What  does  it 
mean?  Nothing  but  this: "that  the  resistance  of  the  child 
to  the  effect  of  external  influences  should  be  strengthened. 
Is  there  a  uniform  method  applicable  to  every  child,  no 
matter  of  what  age  or  constitution?  Certainly  not.  But 
there  is  one  object  which  should  be  accomplished  in  every 
infant  and  child,  viz.,  the  invigoration  of  external  circu- 
lation. The  surface  of  a  child  from  two  to  ten  j^ears 
measures  from  three  to  ten  square  feet.  In  and  under  that 
surface  there  is  a  lake  of  blood.  In  vigorous  health  this 
blood  is  in  constant  and  rapid  circulation;  within  two  min- 
utes it  enters  and  leaves  the  surface,  comes  from  and  leaves 
the  center  of  circulation — the  heart.  Slow  circulation  in 
the  surface  retards  the  flow  of  blood  in  the  whole  body, 
and  impairs  the  nutrition  of  the  heart  and  every  organ, 
causing  congestion  and  insufficient  function,  and  disease. 
Rapid  circulation  in  and  under  the  skin,  causing  rapid 
circulation  everywhere,  propels  the  totality  of  the  blood 
in  the  child's  body  (from  two  to  six  pounds  according 
to  age — from  two  to  twelve  years)  into  and  through  the 
lungs,  in  which  the  contact  with  and  the  absorption  of  the 
oxygen  of  the  atmosphere  take  place.  Now,  the  best  stim- 
ulant of  the  circulation  in  general  is,  besides  muscular 
exertion  (exercise),  the  stimulation  of  the  skin  by  cold 
water  and  friction.  A  child  of  two  or  three  years  should 
have  a  daily  cold  wash,  either  after  a  warm  bath,  or 
standing  in  warm  water  which  covers  the  feet,  or  lying 
on  the  attendant's  lap,  or  on  a  mattress.     A  brisk  rubbing 

404 


PREVENTION  OF  TUBERCULOSIS 

with  a  wet  towel  one  or  two  minutes,  and  with  a  dry  towel 
until  the  surface  is  dry  and  warm,  is  sufficient.  Older 
children  may  have  a  wet  sponge  squeezed  out  over  them, 
this  procedure  being  followed  by  the  same  eiFective  fric- 
tion ;  or  they  may  plunge  into  cold  water,  in  the  winter  a 
single  moment,  in  the  summer  several  minutes.  While  in 
any  bath,  the  skin  should  be  thoroughly  rubbed. 

This  rule  must  not  become  a  routine  applicable  to  every 
individual.  Cold  water  and  friction  require  a  healthy 
heart  and  a  certain  degree  of  strength.  A  usually  healthy 
child,  when  taken  sick  or  when  convalescent  from  a  disease, 
lacks  the  necessary  vigor,  and  the  routine  must  be  inter- 
rupted. A  child  under  size  and  under  weight  requires 
warmer  water  and  friction.  That  is  why  a  newly  born  baby 
or  an  infant  of  less  than  one  or  two  years  should  be 
spared  a  low  temperature.  This  is  also  why  a  child  whose 
feet,  after  a  bath  or  wasliing,  do  not  get  so  warm  as  the 
rest  of  the  body  should  be  rubbed  down,  not  with  cold, 
but  with  warm  water,  or  with  a  mixture  of  alcohol  and 
warm  water  in  which  table  salt  or  sea  salt  has  been  dis- 
solved. 

It  would  be  wrong,  however,  to  rely  on  a  single  method 
alone  for  the  purpose  of  preserving  the  healthy  condition 
of  the  skin,  the  mucous  membrane,  or  the  general  circu- 
lation. Whatever  aids  or  injures  one  part  of  the  body  is 
apt  to  aid  or  injure  all.  No  child  can  have  a  normal 
circulation  in  the  chest  when  the  abdominal  organs  are  com- 
pressed or  their  circulation  interfered  with.  Children,  for 
instance,  who  suffer  from  constipation,  no  matter  from  what 
cause — I  have  described  one  form  which  results  from  an 
abdominal  length  and  bending  upon  itself  of  the  lower  end 
of  the  large  intestines, — or  others  who  suffer  from  pro- 
longed sitting,  or  those  who  bend  over  on  account  of  near-  • 
sightedness,  all  compress  their  abdominal  blood  vessels,  and 
are  often  afflicted  with  nose  bleeding,  congestive  headaches, 
and  general  ill-nutrition.  That  is  one  of  the  frequent  oc- 
currences which  necessitate  the  watchful  care  of  a  school 
physician  and  of  the  teacher. 

Physicians    and    humanitarians    have    always    protested 
against  premature  schooling,  too  long  hours,  and  too  short 

405 


DR.    JACOBFS    WORKS 

recesses,  and  objected  to  overcrowding  of  the  curriculum, 
and  to  the  vanity  of  incompetent  schoohnasters  and  mis- 
tresses, who  utilize  the  poor  victims  in  behalf  of  exhibitions. 
Mostly  in  vain  thus  far.  In  regard  to  the  exhibitions,  and 
the  examinations  preceding  them,  I  am  sure  Dr.  Weir 
Mitchell  has  struck  a  keynote.  Only  last  week  in  a  public 
lecture  delivered  in  Philadelphia,  he  expressed  himself 
strongly  in  regard  to  the  influences  exerted  by  the  worry 
and  fear  and  over-exertion  connected  with  school  examina- 
tions. It  is  true  enough  that  without  some  sort  of  exami- 
nations the  standing  of  the  pupils  in  large  schools  is  hard 
to  determine,  but,  on  the  other  hand,  whoever  has  seen 
much  of  children  or  young  people  about  the  time  of  exami- 
nations must  be  fully  satisfied  that  some  modification  or 
other  must  be  discovered. 

Now,  as  to  school  hours.  A  child  of  seven  or  nine  years 
should  not  have  more  than  two  or  three  hours  daily  in 
school,  one  of  which  should  be  spared  for  an  intermediate 
recess.  From  nine  to  twelve  years  the  school  hours  should 
be  three  or  four;  after  that  age,  not  more  than  five  hours, 
with  frequent  and  ample  recesses.  The  best  exercise  during 
recesses  is  play  in  the  open  air.  Compulsory  gymnastics 
in  badly  ventilated  localities  cannot  take  its  place  success- 
fully and  may  add  to  exhaustion  and  ill-health.  It  is  an 
unforunate  fact  that,  when  the  claims  of  physical  develop- 
ment were  urged  upon  school  authorities,  gymnastics  were 
added  to  the  overcrowded  curriculum  as  a  matter  of  busi- 
ness interest  or  of  conviction,  not  always  willingly  or 
intelligently. 

The  summer  vacations  of  school  children  ought  to  be 
four  weeks  longer  than  they  are.  The  public  schools  ought 
to  be  closed  about  the  middle  of  June  and  reopened  in 
October.  Many  years  ago  the  Harlem  Medical  Associa- 
tion and  the  Medical  Society  of  the  County  of  New  York 
requested  the  Board  of  Education  of  the  city  to  open  the 
public  schools  on  the  third  in  place  of  the  first  Monday  in 
September.  The  soundness  of  the  principle  was  appreci- 
ated and  the  necessity  for  such  a  change  was  acknowledged 
by  the  authorities,  and  the  second  Monday  of  September 
was  selected  for  the  beginning  of  the  school  season,  so  as 

406 


PREVENTION    OF    TUBERCULOSIS 

to  aiFord  the  children  an  extra  week's  broiling  in  the  city's 
sun  and  an  opportunity  to  lose,  as  they  did  formerly,  the 
benefit  derived  from  the  summer  vacation.  The  sanitary 
reason  of  this  loss  of  a  beneficent  opportunity  was  said  to 
be  the  anachronistic  conviction  of  an  eighteenth-century 
school  superintendent,  who  said  he  preferred  the  influence 
of  the  schoolroom  to  that  of  the  New  York  streets  for  the 
New  York  boy. 

Teachers  are  principally  concerned  with  questions  con- 
nected with  the  condition  of  the  school  buildings.  They 
should  be  ample  and  sunny  and  not  moist;  they  should  be 
exposed  to  fresh  air,  have  ample  light  and  sufficiently 
large  rooms.  All  that  appears  to  be  understood,  but  in  this 
very  New  York  we  know  that  not  everything  is  done 
that  could  or  should  be  done  in  regard  to  all  these  postu- 
lates. There  should  be  ample  light,  not  only  for  the  pur- 
pose of  being  enabled  to  see  the  dust  where  it  accumulates 
and  the  mud,  but  light  is  a  remedy  in  itself.  It  is  true 
that  only  in  the  last  very  few  years  has  it  been  utilized 
for  the  direct  cure  of  general  and  particularly  of  local 
diseases,  but  it  was  known  previously  that  disease-giving 
microbes  that  live  a  long  time  in  dark  places  will  be 
speedily  destroyed  under  the  influence  of  light. 

Air  space  should  be  ample.  It  is  difficult  to  say  exactly 
how  many  cubic  feet  are  the  proper  supply.  The  amount 
of  cubic  feet  in  a  schoolroom,  which  is  occupied  a  number 
of  hours  only,  need  not  be  what  it  is  in  a  living-room,  in  a 
bedroom  or  in  a  hospital.  In  the  latter  more  than  1000 
cubic  feet  for  a  person  is  the  least  that  should  be  de- 
manded. We  all  know  that  there  are  few  persons,  com- 
paratively speaking,  in  New  York,  with  its  immense 
tenement-house  population,  that  have  as  much  air  supply 
as  that,  but  we  all  know  how  their  health  suff"ers  from  that 
reason.  A  schoolroom  that  is  occupied  only  a  short  time 
may  perhaps  furnish  about  200  cubic  feet  for  a  child.  A 
room  of  SO  by  25  feet  and  12  feet  high,  containing  QOOO 
cubic  feet  of  air,  should  not  harbor  more  than  50  children. 
At  best  that  would  give  180  cubic  feet  for  each  child.  I 
have  known  of  a  schoolroom,  indeed,  of  many  school- 
rooms, that  were  meant  for  60  children  and  contained  for 

407 


DR.    JACOBI'S    WORKS 

a  long  time  an  excess  of  130.  It  is  natural  that  a  good 
deal  of  sickness  must  be  the  result  among  teachers  and 
pupils. 

Everybody  is  theoretically  convinced  that  the  blood  can- 
not be  fully  aerated,  and  that  the  health  must  suffer,  un- 
less the  air  we  inhale  is  pure.  The  young  organism  suf- 
fers in  this  respect  more  than  the  old,  for  it  requires  more 
oxygen,  comparatively.  Unless  a  sufficient  supply  of  oxygen 
is  kept  up  and  the  percentage  of  carbonic  acid  contained 
in  the  air  is  below  seven-tenths  of  one  per  cent,  good  health 
is  impossible.  The  deteriorations  you  have  to  fight  in  the 
air  of  your  schoolroom  are  as  follows:  It  is  too  dry  under 
the  influence  of  our  heating  apparatus.  Furnaces  and  most 
other  heaters  furnish  a  dry  air  which  impairs  the  surface 
of  the  mucous  membranes  in  the  nose,  the  throat,  and  the 
lungs.  There  is  no  more  voracious  oxygen  eater  than  the 
gas  stove.  Carbonoxid  is  the  result  of  imperfect  combus- 
tion, and  a  very  frequent  deadly  poison.  So  are  the 
chlorine  gas  and  the  nitric  and  sulphuric  acid  contained  in 
our  coal  supply.  They  are  liable  to  change  former  health 
resorts,  on  account  of  the  increase  of  factory  chimneys, 
into  questionable  or  dangerous  localities.  Add  to  this — 
and  you  cannot  exclude  them — the  dust  of  the  houses  and 
streets  with  all  it  contains,  particles  of  stones,  metals, 
vegetable  remnants,  and  microbes,  and,  further,  the  pois- 
onous exhalations  of  the  skin  and  intestines  such  as  sul- 
phides, and  you  will  no  longer  wonder  why  there  are  so 
many  cases  of  catarrh,  bronchitis,  penumonia,  infectious 
fever,  and  tuberculosis. 

The  heating  should  be  considered  one  of  the  most  im- 
portant factors  of  health  or  disease.  The  first  requirement 
of  a  good  heating  apparatus  is  to  give  no  dust  and  not  to 
render  the  air  more  dry  than  it  naturally  is.  Our  wind  in 
New  York  is  mostly  west  wind,  that  deposits  all  the  mois- 
ture before  it  reaches  us.  That  is  why,  as  a  rule,  our  air 
is  very  dry;  that  is  why  our  buildings  dry  out  so  rapidly 
that  they  may  be  inhabited  as  soon  as  finished,  and  our  linen, 
exposed  to  the  air,  dries  in  a  few  hours;  and  that  is  why 
our  heating  apparatus  should  supply  us  with  a  certain 
amount  of  vapor.      Our   furnaces   furnish  a   dry  heat;   so 

408 


PREVENTION  OF  TUBERCULOSIS 

does  most  of  our  steam  heating.  The  result  is  frequent 
catarrhs.  The  temperature  of  a  schoolroom  in  dry  weather 
should  be  about  64  degrees,  in  wet  weather  about  68. 
I  have  been  in  many  schoolrooms  that  are  surely  over- 
heated. In  order  to  modify  the  heat  windows  were  opened. 
The  children  sitting  under  or  near  these  windows  con- 
tract in  a  great  many  instances  a  catarrh,  and  even  pneu- 
monia, and  I  have  seen  them  die  from  such  exposure. 
Perhaps  it  is  too  much  to  expect  circumspection  and  ma- 
ture judgment  from  a  young  teacher.  But  there  should 
be  no  such  thing  as  a  really  immature  teacher.  We  are 
learning  from  our  predecessors,  the  rules  of  hygiene  are 
well  understood,  and  the  people  have  a  right  to  expect 
they  should  be  known  and  obeyed.  In  that  respect,  as  in 
many  others,  a  schoolroom  and  a  school  building,  like  a 
hospital,  should  be  models  for  the  whole  population,  but 
not  dangers.  The  halls  of  a  school  building  should  be 
slightly  cooler,  but  slightly  only,  than  the  schoolrooms,  in 
order  to  avoid  drafts  and  a  sudden  change  of  the  tem- 
perature. 

If  what  I  have  brought  before  you  was  partially  known 
to  5'ou  all,  it  is  a  source  of  gratification  to  me.  The  main 
points  connected  with  the  origin  and  prevention  of  disease 
should  be  known  to  every  educated  person.  Only  in  this 
way  the  public  at  large,  which  has  to  rely  on  superior 
judgment  and  is  unfortunately  more  readily  led  astray 
than  guided  correctly,  can  be  benefited.  We  doctors  are 
never  more  pleased  than  when  our  patients  understand  the 
why  and  wherefore,  in  the  same  way  that  you  are  most 
enchanted  with  pupils  that  ask  for  and  comprehend  the 
why  and  wherefore.  Unfortunately  no  walk  in  life  is  proof 
against  ignorance.  Moreover,  our  education  is  too  often 
an  instruction  which  runs  in  ruts.  Nothing  is  more  common 
than  that  men  and  women  of  good  minds  and  moral  in- 
stincts should  be  satisfied  or  compelled,  by  lack  of  time  or 
opportunities,  to  neglect  widening  the  horizon  of  their  men- 
tal possessions  beyond  what  is  nearest  to  their  profession 
or  inclinations.  That  is  why  thousands  in  our  better 
classes  are  so  often  the  victims  of  quackery  and  sectarian- 
ism, of  faith   cures,  clairvoyance,   and  un-Christian   "  sci- 

409 


DR.    JACOBI'S    WORKS 

ence."  Faith  belongs  to  the  realm  of  religion,  not  of  science 
— of  the  other,  not  of  this  world.  Now,  the  professions  of 
doctor  and  teacher  are  least  apt  to  be  caught  by  glittering 
improbabilities  or  impossibilities.  We  teach  the  realities 
of  both  the  physical  and  the  intellectual  world.  That  is 
why  it  has  given  me  intense  pleasure  to  speak  before 
you,  though  well  aware  that  in  a  brief  time  I  could  pre- 
sent to  you  but  "little  that  is  foreign  to  you,  or  too  little 
of  what  you  had  a  right  to  expect.  In  what  I  have  said 
there  may  be,  however,  a  few  practical  points  of  value. 
In  your  professional  work,  and  in  your  social  contact  with 
the  little  and  the  big  ones,  you  will  have  ample  oppor- 
tunity, I  hope,  to  put  them  into  effect. 


410 


CAUSES  OF  EPILEPSY  IN  THE  YOUNG 

The  two  series  of  the  Index  Catalog  of  the  Surgeon- 
General's  library  contain  125  columns  filled  in  close  print 
with  the  titles  of  books,  pamphlets  and  magazine  articles 
on  epilepsy.  In  the  presence  of  such  a  mountain  of 
erudition,  I  felt  I  could  do  no  better  than  to  refer  the 
anxious  litterateur  to  those  wonderful  volumes,  the  pride 
and  honor  of  American  medicine,  and  confine  the  few  min- 
utes at  my  disposal  to  the  elaboration,  in  as  few  and  as 
plain  words  as  possible,  of  some  personal  experiences,  be- 
liefs, and  criticisms  connected  with  the  causes  of  epilepsy 
in  the  young.  I  take  it  that  meetings  like  these  should  add 
to  the  learning  collected  in  libraries  the  inspiration  of  per- 
sonal  intercourse. 

The  predisposition  to  epilepsy  may  be  inherited,  or 
acquired  during  intrauterine,  or  during  extrauterine  life- 
Intoxications  of  the  parents  by  morphin,  lead,  or  alcohol, 
their  infection  with  syphilis  or  tuberculosis,  their  constitu- 
tional anemia,  gout,  or  diabetes,  or  a  local  degeneration 
of  either  testes  or  ovaries  may  not  cause  in  the  offspring 
the  identical  disease  or  anomaly,  but  only  a  general  debil- 
ity of  the  tissues  or  their  innervation.  A  variety  of  causes 
may  have  the  same  result,  and  a  variety  of  results  may  fol- 
low an  identical  cause.  Quite  often  the  unexpected  is 
the  rule,  and  a  general  neuropathy  is  more  frequently  ob- 
served than  a  direct  inheritance.  Still,  epilepsy  appears 
to  be  more  directly  inherited  than  any  other  cerebral  dis- 
order. In  Echeverria's  533  cases,  29-72^  showed  a  direct 
inheritance  from  an  epileptic  parent;  Gowers  has  a  per- 
centage of  35;  according  to  Spratling,  66%  of  the  epileptic 
children  have  epileptic  parents.  Whether,  and  to  what 
extent,  matrimony  between  relatives  contributes  to  men- 
tal disease  or  degeneration  is  by  no  means  proved.  From 
theoretical  reasoning,  from  personal  experience,  and  from 

411 


DR.    JACOBI'S    WORKS 

the  incompetence  of  statistics,  which  are  amenable  to  a 
contradictory  variety  of  conclusions  when  handled  by  dif- 
ferent reviewers  with  different  horizons  and  standpoints,  I 
cannot  admit  that  two  healthy  persons,  be  they  ever  so 
closely  related,  must,  for  the  reason  of  consanguinity, 
have  a  diseased  child.  But  to  what  extent  the  state  of  the 
future  will  interfere  with  the  marriages  of  insane  or  epilep- 
tic people,  as  also  with  those  of  carcinomatous  or  thor- 
oughly tuberculous,  remains  to  be  seen.  I  can  imagine 
and  believe  that  the  offspring  of  the  intellectually  and 
morally  healthy  couple  will — other  things  being  equal  and 
barring  the  accidents  of  pregnancy  and  birth — serve  the 
improvement  of  the  race,  while  that  of  the  abnormal  must 
impair  it.  From  that  point  of  view  we  should  look  for- 
ward with  hopeful  expectations  to  a  little  more  paternal- 
ism in  our  government.  There  is  no  country  in  the  world 
in  which  a  monarchy  is  less  probable,  and  the  government 
of,  for  and  by  the  people  is  more  certairr  to  come  than  in 
ours ;  for  there  is  none  in  which  the  organization  of  capital 
and  the  organization  of  labor  are  making  such  rapid  strides 
towards  a  peaceful  evolution  of  socialism  as  in  ours.  That 
is  why  the  younger  men  among  us  will  live  to  see  the  time 
in  which  the  sanitation  of  the  courrtry  and  people,  guided 
by  the  legislative  influence  of  the  medical  profession,  will 
render  impossible  the  perpetuation  of  deteriorating  or  loath- 
some diseases. 

It  is  probably  impossible  ever  to  ascertain  the  exact 
number  of  infant  or  young  epileptics.  Neither  public  in- 
stitutions nor  specialists  are  iir  a  position  to  gather  exact 
statistics.  Very  few  are  as  favorably  situated  as  Gowers, 
Binswanger,  and  others.  Institutions  are  filled  with 
patients  in  advanced  years,  specialists  see  them  mostly 
in  the  same  way.  Many  an  epileptic  infant  or  child  dies 
before  being  observed  or  treated,  or  even  diagnosticated; 
for  a  great  many  cases  of  petit  mal,  vertigo,  dream-like 
states  and  somnambulism,  fainting,  even  hysteric  spells, 
are  overlooked.  They  are  neglected  or  cared  for  at  home, 
and  the  seizure  is  taken  to  be  an  eclamptic  attack.  An 
example  of  the  kind  is  now  in  my  hospital  ward;  a  child 
with  nephritis   after  scarlatina  which  ran  its   course   four 

412 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

months  ago.  While  practically  in  convalescence  he  was 
taken  with  an  "  eclamptic  "  attack  a  few  days  ago.  As 
there  was  a  daily  renal  secretion  of  from  500  cc.  to  600  cc, 
a  percentage  of  more  than  2  of  urea,  and  no  indiscretion 
in  his  diet,  the  diagnosis  of  a  uraemic  intoxication  was  out 
of  the  question.  That  obliged  us  to  inquire  into  his  past, 
with  the  result  of  our  learning  the  history  of  several  un- 
provoked convulsions  of  epileptic  character  in  the  course 
of  the  last  18  months.  It  is  the  general  practitioner  who 
sees  the  cases  and  is  able  to  judge  of  them  according  to 
their  merits.  He  does  not  record  them,  but  has  more 
facilities  to  see  them  than  even  a  public  dispensary.  Many 
of  these  patients  are  discovered  in  dispensaries  and  col- 
lege clinics  only  after  a  number  of  attacks  have  occurred 
and  succeeded  in  rousing  the  suspicions  of  the  parents. 
With  all  these  drawbacks,  however,  I  am  certain  that  I 
have  seen  many  hundreds  of  such  cases  in  the  course  of 
marry  years.  The  actual  or  the  proximate  cause  of  general- 
ized epilepsy  is  in  the  cerebral  cortex;  its  origin  in  ana- 
tomic lesions  of  different  localities.  Thus,  epilepsy  may  be 
cerebral,  it  may  be  the  result  of  persistently  abnormal 
circulation,  or  it  may  be  of  a  reflex  nature.  All  sorts  of 
cerebral  tumors,  solid  or  cystic;  the  results  of  previous 
encephalitis  and  meningitis,  from  insolation,  otitis,  nasal 
infection,  or  otherwise;  disseminated  sclerosis  of  different 
territories;  "vasculitis"  of  the  pia  mater;  the  results  of 
haematomata  or  of  thromboses ;  arrests  of  cerebral  develop- 
ment of  heterotopy  of  gray  substance;  premature  ossi- 
fication of  one,  some,  or  all  of  the  cranial  sutures  and  fon- 
tanelles ;  even  the  narrowness  of  the  occipital  foramen ; 
cerebral  exhaustion  from  masturbation  or  premature  venery, 
or  local  anaemia  of  known  or  unknown  origin ;  diseases  of 
the  heart  with  secondary  venous  obstruction;  congestion 
from  other  causes  (in  a  case  of  Gerhardt's,  enlargement 
of  the  thyroid)  ;  the  influence  of  prolonged  use  of  alcohol 
or  ergot;  the  sluggish  brain  circulation  attending  constipa- 
tion and  the  general  toxaemia  of  intestinal  autoinf ection ; 
external  irritations,  such  as  peripheral  tumors,  cicatrices, 
foreign  bodies,  and  the  reflex  excitement  produced  by 
carious    teeth,    Schneiderian    hypertrophy,    and    nasal    and 

413 


DR.    JACOBI'S    WORKS 

naso-pharyngeal  growths ;  vesical  and  renal  calculi ;  hel- 
minthes,  from  taenia  to  oxyuris ;  in  older  children  delayed 
menstruation,  are  so  many  different  causes  of  epilepsy. 
It  is,  therefore,  only  the  most  painstaking  examination  of 
all  the  organs  and  the  whole  surface  of  the  body  which 
gives  a  promise  of  finding  the  cause  of  the  disease  as  well 
as  the  indications   for  rational  causal  treatment. 

Jachsonian  epilepsy  affects  a  localized  group  of  mus- 
cles, and  always  the  same;  the  spasm  is  mostly  clonic  and 
painless,  and  when  it  becomes  generalized  the  attack  be- 
gins in  the  same  order.  It  is  frequently,  perhaps  mostly, 
the  result  of  a  coarse  lesion,  a  detached  bone,  a  tumor, 
an  abscess,  a  localized  patch  of  meningitis,  a  hematoma, 
a  cyst,  a  cicatrix,  or  a  foreign  body  which  by  irritation 
sets  up  a  series  of  epileptic  convulsions.  A  (brachial) 
Jacksonian  epilepsy  was  cured  by  the  removal  of  a  for- 
eign body  from  the  ear  by  Monflier.  But  this  relation 
between  a  Jacksonian  epilepsy  and  a  local  disorder  can- 
not always  be  proved.  Exceptions  are  very  numerous ; 
only  lately  Z.  Bregman  and  N.  Odefeld  ^  came  to  the  con- 
clusion that  "  a  tumor  occupying  a  large  part  of  the  sur- 
face of  the  frontal  lobe  may  look  like  a  lesion  of  the  cen- 
tral convolution.  A  persistent  paralysis  of  monoplegic 
character  and  suggesting  localization  in  the  cortex  Avith 
symptoms  of  Jacksonian  epilepsy  need  not  prove  a  lesion 
of  the  motor  zone.  Finally,  there  may  be  an  extensive 
lesion  of  the  frontal  lobe  without  corresponding  symptoms." 
I  may  add  from  my  own  experience  that  many  a  case  of 
Jacksonian  epilepsy,  when  examined  postmortem,  exhibited 
no  tangible  cause.  That  is  also  why  many  an  operation 
undertaken  for  relief  was   futile. 

Intrauterine  influences,  both  inflammations  and  intoxica- 
tions, are  certainly  powerful  as  occasional  causes  of  epi- 
lepsy. Hereditary  syphilis  is  considered  a  frequent  cause 
of  epilepsy,  both  Jacksonian  and  universal.  The  former 
results  from  the  localization  of  an  organic  disease  of  the 
brain,  either  meningitis,  or  encephalitis,  or  softening,  or 
gummatous    infiltration.      In   accordance   with   their   extent 

1  Grenzgeb.  Med.  Chir.,  1902,  p.  516. 
414 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

or  localization  there  are  symptoms  of  either  paralysis  or 
irritation.  When  epilepsy  is  universal  or  genuine,  no  such 
localization  or  local  symptoms  are  met  with.  These  cases 
show  the  fate  of  all  those  which  permit  of  nothing  but  the 
assumption  of  an  unrecognized  cortical  alteration.  When 
children  of  five  or  seven  years  are  suddenly  attacked  with 
epilepsy,  syphilis  should  be  suspected.  These  children  are 
generally  undersized  and  puny,  such  as  Fournier  has  pic- 
tured as  parasyphilitic.  I  have  often  seen  and  discussed 
them  from  that  point  of  view,  but  must  confess  that  though 
in  the  majority  no  serious  nervous  disorders  seemed  to  mark 
their  appearance,  in  many,  however,  though  no  history  of 
syphilis  of  the  parents  could  be  elicited,  visceral  lesions; 
were  found  in  autopsies.  Nor  are  other  nervous  diseases 
of  early  age  exempt  from  syphilis.  In  hydrocephalus  it 
is  frequent,  in  polioencephalitis  rare.  In  200  cases  of  this 
form  of  paralysis,  Sachs  found  only  2  that  were  attribu- 
table to  hereditary  syphilis.  From  a  similar  point  of  view 
mostly,  the  whole  subject  is  thoroughly  treated  in  a  classi- 
cal book  on  "  Syphilis  and  the  Nervous  System,"  by  Max 
Nonne,  Berlin,  1902. 

The  conclusion  should  be  that  there  are  not  many  cases 
of  epilepsy  that  can  be  directly  attributed  to  syphilis. 
But  a  great  many  epileptics  exhibit  symptoms  that  make 
them  very  suspicious.  Such  are  early  imbecility  or  idiocy, 
glandular  swellings,  chronic  periostitis,  and  anomalous 
teeth.  Not  infrequently  I  found  in  a  family  several  cases, 
one  case  of  epilepsy  and  others  of  different  cerebral  dis- 
orders. It  appears,  therefore,  that  the  syphilitic  virus, 
more  or  less  modified,  acts  on  the  germ  from  the  beginning 
of  embryonal  life  with  different  results. 

In  this  respect  it  resembles  other  influences  which  con- 
trol the  predisposition  to  epilepsy,  gout,  diabetes,  hysteria, 
or  insanity,  which  are  prevalent  in  a  family  in  one  of  the 
two   preceding   generations. 

Many  intrauterine  influences  exhibit  themselves  imme- 
diately or  soon  after  birth.  Among  them  I  may  be  per- 
mitted to  speak  of  hypertrophy  of  the  brain,  premature 
ossification  of  the  cranium,  and  spurious  meningocele. 

Genuine  hypertrophy  of  the  brain  is  not  frequent,  but 
415 


DR.    JACOBI'S    WORKS 

I  have  seen  it  once  with  epilepsy  that  began  when  the  cliild 
was  a  year  old  and  persisted  until  the  autopsy  was  made 
three  years  later.  The  cranium  was  of  normal  thickness ; 
20  teeth  had  protruded.  The  dura  mater  was  tightly  ad- 
herent to  the  cranium,  pale  and  tense.  When  it  was  in- 
cised the  solid  cerebral  substance  bulged  through  the  in- 
cision. The  brain  surface  was  pale  and  flattened  and  the 
cortex  of  fair  diameter;  the  white  substance  pale,  hard, 
massive;  the  ventricles  small,  with  no  serum.  As  early  as 
1806"  and  1828^  Laennec  reported  that  in  several  cases 
diagnosticated  by  him  as  hydrocephalus  he  found  no  serum, 
but  the  flattened  convolutions  of  a  pale,  compressed,  elastic 
brain.  Huf eland  (1824)  admitted  to  have  made  the  same 
mistake.  It  was  he  who  first  described  the  bulging  of  the 
elastic  brain  through  the  incision  of  the  dura  mater.  His 
cases  of  this  real  cerebral  hypertrophy — that  is,  a  large 
brain  within  a  normal  skull — and  those  of  other  older 
writers  are  referred  to  in  E.  Noeggerath  and  A.  Jacobi's 
"  Contributions  to  Midwifery  and  Diseases  of  Women  and 
Children,"  New  York,  1859,  p.  84.  Altogether,  however, 
these  cases  of  abnormal  hypertrophy  of  the  white  substance 
appear  to  be  rare;  they  should  be  carefully  distinguished 
from  the  large  brains  of  Byron,  Cuvier,  Turgenieif,  and 
Cromwell,  that  were  symmetrically  large.  I  think  I  am 
prepared  to  say  that  the  epilepsy  in  my  case  resulted  from 
the  hypertrophy  of  the  white  substance  and  the  compres- 
sion of  the  cortex.  There  was  no  other  tangible  hyper- 
trophy. Possibly  it  was  the  latter  alone  that  caused  it,  for 
hypoplasia  of  the  cortex  is  reported  as  the  condition  of  a 
young  man  who  died  in  an  epileptic  attack,  by  Ziegler  in 
the  second  volume  of  his  "  Pathological  Anatomy." 

Hypertrophy  of  the  brain,  that  is  an  abnormal  and  ab- 
normally large  brain  enclosed  in  a  normal  skull,  must  be 
distinguished  from  premature  ossification  of  the  fontanelles 
and  sutures.  In  this  interesting  condition  we  have  to  deal 
with  an  originally  normal  brain  tightly  enclosed  in  an  ab- 
normal cranium.     In  the  book  I  quoted  and  in  the  Journal 

2  Journal  de  M^d.  Chir.  et  Pharm.,  p.  669.  3  Revue  Med. 

416 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

of  Medicine  of  1857,  I  wrote  "  on  the  etiological  and  prog- 
nostic importance  of  the  premature  closure  of  the  fon- 
tanelles  and  sutures  of  the  infantile  cranium."  The  ob- 
servations of  this  anomaly  were  at  that  time  only  few. 
Extensive  studies  of  the  subject  had  been  made  by  Vir- 
chow,  Huschke,  and  Lucae.  Hyrtl  was  the  first  to  show 
that  pathologic  forms  of  the  skull  might  depend  on  the 
premature  closure  of  single  sutures.  Cruveilhier,  Bail- 
larger,  and  Schiitzenberger  reported  cases.  Gratiolet 
studied  (1856)  the  direct  relation  of  cranial  ossification  in 
different  races  with  their  intellectual  development  and 
found,  for  instance,  that  the  coronal  suture  closes  earlier 
in  the  negro  than  in  the  white,  and  that  the  receding  fore- 
head and  bulging  occiput  of  the  former  depend  on  this 
precocity  of  bone  ossification.  I  approached  the  question 
from  a  nosological  point  of  view.  A  few  of  the  conclu- 
sions at  which  I  arrived,  and  which  are  still  justified,  are 
as  follows:  A  brain,  in  order  to  arrive  at  its  normal  de- 
velopment, must  have  space.  The  normal  closure,  not 
genuine  ossification  yet  of  the  sutures  and  large  fontanelle, 
takes  place  about  the  fifteenth  month  of  life.  After  that 
time  the  growth  of  the  brain,  which,  however,  does  not  en- 
tirely terminate  before  the  sixtieth  year,  becomes  very 
slow.  When  ossification  is  premature,  the  brain  when 
normal  cannot  grow,  is  compressed  in  its  entirety.  When 
synostosis  is  uniform  the  shape  of  the  head  is  nearly  spheri- 
cal, when  it  is  local  the  corresponding  part  of  the  skull 
and  brain  is  rather  flattened,  while  the  opposite  is  bulging. 
In  this  way  the  asymmetry  of -the  skulls  of  many  epileptics 
as  described  by  Riecken  and  by  Miiller  *  is  easily  explained. 
When  the  cranium  is  sunk  in  in  one  or  more  places,  for 
instance  on  and  above  the  two  temporo-parietal  regions,  the 
case  cannot  be  one  of  premature  ossification  over  an  origi- 
nally normal  brain,  but  is  one  of  genuine  microcephalus 
depending  on  an  arrest  of  development.  The  suggestion  of 
craniotomy  or  craniectomy  in  a  case  of  real  premature  ossi- 
fication  may   still   be  justified,  the  fatality  or  uselessness 

4  Virchow's  Handbuch,  Vol.  iv. 
417 


DR.    JACOBI'S    WORKS 

of  such  operations  notwithstanding.  I  have  not  changed 
my  conviction  on  that  subject  expressed  in  my  Roman 
address  "  non  nocere  "  of  1894.  Their  performance  by 
enterprising  operators  in  cases  of  undiagnosticated  or  mis- 
taken microcephalia — no  matter  whether  the  fontanelle  is 
large  or  small,  or  the  bone  is  thin  or  firm — is  no  longer  a 
medical  question.  Where  nature  made  a  mistake  the  doc- 
tor must  not  believe  he  can  correct  it  by  a  crime. 

The  diagnosis  is  not  difficult.  When  the  case  is  one  of 
ossification  at  birth  it  is  only  the  exaggeration  of  what  may 
be  observed  to  develop  slowly  after  birth.  In  these  cases 
the  cranial  bones  harden,  the  fontanelle  decreases  in  size 
instead  of  its  normal  enlargement  up  to  the  eighth  month. 
They  may  close  at  the  third,  sixth,  tenth  month.  All  the 
connective  tissues  of  the  cranium  develop  at  the  same  rate. 
Many  such  infants  begin  to  use  their  limbs  early.  The 
teeth  appear  early  and  not,  as  in  occasional  cases  of  rhachi- 
tis,  in  long  intervals,  but  in  rapid  succession.  The  first 
teeth  to  appear  are  not,  as  in  the  healthy,  the  lower  incisors, 
but  the  upper.  These  symptoms,  together  with  the  shape  of 
the  head  as  described  before,  justify  your  diagnosis.  After 
a  while  the  general  development  is  disturbed  by  the  in- 
creasing pressure,  or  irritation,  by  the  interference  with 
intracranial  circulation,  and  by  the  additional  danger 
caused  thereby  to  every  occurrence  of  a  slight  or  serious 
ailment.  During  such  a  complication  the  first  convulsion 
may  take  place.  Often  it  occurs  without  any  premonitory 
symptom,  and  will  return  in  irregxilar  intervals.  Cases 
in  which  epilepsy  of  later  years  is  due  extensively  to  the 
compression  of  an  originally  normal  brain  in  an  abnormally 
compact  and  uniformly  contracted  skull  I  have  seen.  But 
more  are  due  to  or  connected  with  a  premature  partial  syn- 
ostosis. There  are  but  few  normal  heads  and  brains  in 
the  well  absolutely  symmetrical;  but  it  is  the  fate  of  a  great 
many  epileptics  to  have  a  comparatively  small  cranial  cir- 
cumference and  an  absolutely  asymmetrical  shape. 

Savage  nations'  have  made  observations  which  show  their 

5  A.  Jacob!:    The   Intestinal   Diseases   of  Infancy   and   Child- 
hood, Detroit,  188T,  p.  103. 

418 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

fear  of  such  art  occurrence.  The  Makalaka  of  South 
Africa  are  always  anxious  to  look  for  the  location  of  the 
first  teeth,  whether  in  the  upper  or  lower  jaw.  In  Bohe- 
mia it  is  a  popular  belief  that  the  child  whose  upper  in- 
cisors come  first  will  soon  die.  David  Livingstone  and 
Fritzsch  report  that  some  nations  in  Central  Africa  kill 
the  infants  whose  upper  incisors  protrude  before  the  lower 
ones. 

Meningocele  spuria  means  a  fissure  of  the  cranium  and 
of  the  tightly  adherent  dura  mater  under  an  intact  scalp. 
It  is  the  result  of  a  forceps  operation,  of  a  fall  or  some 
other  trauma,  of  caries,  or  of  syphilis.  When  the  fissure 
is  superficial  it  need  not  interfere  with  the  development 
of  the  brain,  for  there  is  not  even  a  permanent  loss  of 
cerebrospinal  liquor,  but  when  it  is  injured  down  to  a 
lateral  ventricle  it  results  in  porencephalia.  Rhachtis  of 
the  cranial  bones,  and  the  interposition  of  brain  substance 
between  the  fissured  bones  prevents  spontaneous  recovery. 
A  practical  recovery  without  operation  may  take  place  by 
the  interposition  of  the  membranes  and  of  some  periosteum. 
This  spontaneous  process  may  proceed  kindly,  but  irrita- 
tion of  the  compressed  parts  may  cause  meningitis  and 
epilepsy.  I  made  the  autopsy,  20  years  ago,  of  a  child  5 
years  old. 

I  had  seen  her  once  when  she  was  a  few  months  old,  with  spuri- 
ous meningocele  attributed  to  a  forceps  operation.  When  she 
was  about  a  year  old  she  had  a  violent  convulsion  preceded  by 
numerous  spells  of  petit  mal.  Before  she  died  these  were  num- 
berless; severe  epileptic  seizures  there  were  no  more  than  half  a 
dozen  all  told.  She  had  a  moderate  amount  of  liquor  in  the  lat- 
eral ventricles  and  some  oedema  and  thickening  of  the  choroid 
plexus.  Round  the  fissure  of  the  right  parietal  bone,  which  was 
closed  by  interposed  cicatricial  and  hard  tissue,  there  was  inside  a 
pale,  hard  pachymeningitis,  the  alteration  extending  over  3  cm. 
in  every  direction,  and  a  thickened  pia,  pale  near  the  origin  of 
the  affection,  hyperaemic  with  large  veins  to  a  distance  of  10  cm. 
or  12  cm. 

It  appears  that  with  the  possibility  of  its  resulting  in 
epilepsy  even  a  spurious  meningocele  should  not  be  left 
alone.    A  recent  case  demands  the  raising  of  the  depressed 

419 


DR.    JACOBFS    WORKS 

bone  and  either  bone  or  periosteum  suture.  Older  cases,  if 
pronounced  inoperable,  should  be  protected  by  a  pad; 
iodine  injections  have  proved  successful;  dropsical  lateral 
ventricles  may  be  drained. 

In  the  foregoing  remarks  I  have  directed  your  attention 
to  the  unpromising  results  of  intrauterine  influences.  Let 
me  turn  to  another  subject,  in  order  to  show  that  there 
are  other  powerful  influences  for  bad,  the  results  of  which 
may  be  more  frequently  prevented  than  cured. 

A  frequent  cause  of  epilepsy  is  asphyxia  of  the  new- 
born, frequently  the  first  born — no  matter  from  what  cause : 
moderate  or  serious  compression  of  the  fetal  head,  com- 
pression or  prolapse  of  the  cord,  intrauterine  respiration 
and  aspiration  of  liquor  amnii  or  meconium,  placentar  de- 
tachment, morphine  or  chloral  poisoning  by  the  maternal 
blood,  malformations  of  intrathoracic  or  intracranial  or- 
gans, etc.  The  anatomical  results  in  the  cranium  are  ex- 
cessive hyperaemia,  tense  veins,  sanguineous  eff'usion,  ex- 
travasation, and  thrombosis.  When  the  baby  lives  at  all, 
a  meningitis  or  meningoencephalitis  may  follow,  and  par- 
alysis in  many  cases;  in  many  more,  idiocy  or  epilepsy  or 
both  are  the  final  results.  In  one-third  part  of  the  cases 
of  idiocy  there  is  a  combination  with  epilepsy.  In  a  long 
life  I  could  trace  the  cause  of  the  two  latter  to  asphyxia 
in  hundreds  of  cases.  Without  any  suggestions,  my  ques- 
tion. Did  the  baby  cry  when  born,  or  did  the  baby  live 
when*  born  ?  is  answered  that  it  did  not ;  that  the 
doctor  worked  over  the  baby  minutes  or  quarter  hours 
before  it  was  resuscitated,  and  that  the  baby  never 
was  like  other  infants,  never  smiled  at  the  usual  time, 
took  little  or  no  notice,  and  had  general  convulsions  some- 
times beginning  on  one  side,  quite  often.  Hundreds  of 
such  cases  I  had  opportunities  to  present  at  my  clinics; 
never  without  the  warning  to  my  classes  that  the  para- 
mount duty  of  the  practitioner  is  to  shorten  asphyxia,  and 
that  there  is  nothing  connected  with  the  management  of  a 
case  of  labor  so  vital  as  the  prevention  or  shortening  of 
asphyxia,  the  attendance  upon  the  mother,  though  ever  so 
urgently  demanded,  not  excepted.  A  single  moment  more 
or  less  of  the  asphyxiated  condition  may  decide  the  future 

420 


CAUSES   OF    EPILEPSY    IN   THE   YOUNG 

of  the  newborn,  and  the  presence  or  absence  of  a  para- 
lytic, idiotic,  or  epileptic  misfit  in  human  society. 

The  same  danger  accompanies  intracranial  hemorrhages 
not  connected  with  asphyxia  of  the  newborn.  They  are 
very  frequent.  The  majority  of  babies  who  die  in  their 
first  week  succumb  from  that  cause.  The  proximate  cause 
may  be  found  in  disturbance  of  the  circulation  or  in  a 
trauma,  but  the  disposition  results  from  the  incomplete 
embryonal  structure  of  the  blood-vessel  walls.  This  dis- 
position to  extravasation  is  as  great  in  the  newborn  as 
it  is,  for  other  reasons,  in  the  senile  condition  of  the  arte- 
ries, very  rarely  the  veins,  of  advanced  age.  The  danger 
to  life  is  increased  in  the  former  by  the  lack  of  coagula- 
bility of  the  fetal  and  infant  blood  which  causes  the  extrav- 
asation to  be  very  copious  indeed.  When  it  is  not  ex- 
cessive, it  may  not  destroy  life — the  more  is  the  pity — but 
the  clot  and  the  secondary  inflammation  and  degeneration, 
and  now  and  then  the  final  development  of  a  cyst  of  the 
dura  mater,  will  cause  hemiplegia,  paralysis,  idiocy,  epi- 
lepsy. Many  are  the  instances  in  which  I  could  find  what 
pointed  unmistakably  to  the  connection  of  the  hemorrhage 
with  the  subsequent  life-long  disturbance. 

The  frequency  of  convulsions  in  infancy  and  childhood 
is  another  danger.  Those  of  the  first  six  weeks  or  two 
months  of  life  are  of  cerebral  origin;  that  is  the  period 
in  which  clinical  experience  and  Soltmann's  experiments 
teach  us  that  reflexes  are  absent  or  feeble.  After  that 
time  convulsions  are  either  reflex  or  toxic.  No  matter, 
however,  how  they  are  produced,  every  convulsion  is  a 
danger  to  the  brain  by  the  possibility  of  blood-vessel  rup- 
ture. Small  or  large  extravasations  may  occur  in  every  con- 
vulsion, no  matter  from  what  cause,  and  endanger  life, 
or  mind,  or  health.  The  location  or  the  size  of  the  hemor- 
rhage and  the  dignity  of  the  aff"ected  part  are  of  the  great- 
est import.  The  danger  is  not  so  great  when  the  fontanelles 
and  sutures  are  not  yet  closed,  and  the  expansible  blood 
vessels  may  be  able  to  harbor  a  larger  amount  of  blood 
without  being  torn  in  their  weakest  capillary  terminations; 
a  fully  or  a  prematurely  ossified  cranium  furnishes  a  greater 
disposition  to  hemorrhage.     All  this  may  happen,  no  matter 

421 


DR.    JACOBI'S    WORKS 

what  caused  the  convulsion — intestinal  irritation  by  un- 
digested food  or  helminthes,  acute  intoxication  by  alcohol, 
cocci  or  bacilli  or  their  toxins,  in  scarlatina,  typhoid  or  in- 
fluenza, uraemia,  inanition,  whooping  cough  or  laryngismus. 
Two  cases  of  epilepsy  I  remember  distinctly  that  were 
caused  by  the  convulsions  of  whooping  cough.  Another  was 
due  to  an  apoplexy  in  an  adult.  The  unfortunate  young 
man  suffered  from  unmanaged  constipation.  I  was  called 
40  odd  years  ago  to  see  him  in  a  fit  of  what  was  called  a 
fainting  spell.  I  found  him  on  the  water  closet  with  an 
apoplectic  attack  that  soon  terminated  in  hemiplegia  of  the 
right  side.  A  year  afterward  he  had  his  first  attack  of 
epilepsy,  which  was  followed  by  a  great  many  more  until 
he  died,  long  after  from  what,  according  to  the  report  of 
the  case,  appeared  to  be  a  second  attack  of  cerebral  hemor- 
rhage. Cases  of  cerebral  hemorrhage  occasioned  by  a  con- 
vulsion in  a  child  can  be  treated,  but  rarely  cured ;  but  many 
may  be  prevented  by  the  speediest  possible  interference  with 
the  attack.  No  case  of  eclamptic  convulsion  should  be  left 
alone.  It  requires  chloroform,  no  matter  what  other  in- 
dications present  themselves.  Shortening  of  a  convulsion 
from  any  source,  cerebral  or  reflected,  by  a  single  half 
minute,  may  just  be  in  time  to  prevent  a  hemorrhage  and 
subsequent  death,  or  what  is  worse,  paralysis,  spastic 
encephalitis,  idiocy,  or  epilepsy. 

The  causes  of  convulsions  in  infancy  and  early  child- 
hood are  so  numerous  and  their  dangers  so  many  that  it 
may  be  worth  our  while  to  spend  a  few  minutes  in  the 
consideration  of  at  least  a  few  of  them,  with  the  object  of 
facilitating  an  early  diagnosis  and  the  possibility  of  imme- 
diate and  correct  treatment.  They  are  so  many,  some  of 
them  not  generally  appreciated,  that  it  will  pay  us  to  elim- 
inate one  at  least  that  is  credited  with  more  mischief  than 
it  is  guilty  of.     I  mean  dentition. 

William  Philip  Spratling  "  expresses  himself  as  follows : 
"  Next  to  heredity,  it  is  my  firm  conviction  that  dentition, 
when  severe,  and  when  acting  on  an  organism  thai  hears  the 
impress  of  transmitted  weaknesses,  plays  the  most  important 

6  Medical  News,  September  15,  1894. 
422 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

role  in  causing  epilepsy  in  early  life.  Indeed,  I  fully  be- 
lieve that  the  importance  of  teething  in  this  respect  has 
not  been  accorded  the  careful  attention  it  deserves."  Dr. 
Spratling  fortifies  his  position  by  quotations  from  Gowers 
and  from  replies  received  to  a  circular  inquiry.  From 
among  the  latter  he  prints  quotations  taken  from  letters 
written  by  me,  Dr.  G.  Elder  Blumer,  Graeme  M.  Ham- 
mond, Frederick  Peterson,  and  T.  S.  Clouston,  of  Edin- 
burgh. From  Gowers  the  following  words  are  quoted:  "  Of 
all  the  cases  that  commence  in  infancy,  at  least  three- 
quarters  date  from  infantile  convulsions  ascribed  to  teeth- 
ing." I  wish  you  to  note  that  the  words  are  "  ascribed 
to  teething,"  not  due  to  teething.  I  have  no  doubt  he  meant 
to  say  "  ascribed  to  teething  by  the  men  who  sent  me  the 
cases  and  their  histories."  Gowers"  says,  literally:  "The 
influence  of  the  process  of  the  eruption  of  the  teeth  is 
relegated  to  its  proper  place,  as  merely  a  possible  excitant 
in  a  few  cases."  From  my  letter  Dr.  Spratling  quotes  as 
follows :  "  Every  convulsion,  ever  so  slight  or  short,  may 
produce  cerebral  hemorrhage,  with  all  the  possible  results — 
epilepsy,  idiocy,  paralysis,  and  insanity.  Such  cases  are, 
unfortunately,  frequent."  You  will  notice  that  teething 
is  not  mentioned  by  me.  I  certainly  did  not  believe,  nor 
did  I  mean  to  infer,  that  the  convulsions  spoken  of  were 
due  to  dentition.  Dr.  Blumer  expresses  his  belief  that 
"  there  is  no  such  thing  as  a  convulsion  due  to  dentition 
pure  and  simple  and  uncomplicated."  Dr.  Spratling  him- 
self emphasizes  the  requirement  of  the  "  impress  of  trans- 
mitted weaknesses  "  that  one  must  go  back  of  the  denti- 
tion and  regard  the  disturbance  of  this  process  as  the 
"  mere  existing  cause  of  the  explosion."  Dr.  Hammond 
has  "  records  of  several  cases  in  which  convulsions,  due  to 
dentition,  were  followed  by  true  epileptic  convulsions."  Dr. 
Peterson  "  can  recall  a  number  of  cases  of  epilepsy  due  to 
the  convulsions  of  dentition."  Dr.  Clouston  is  more  posi- 
tive than  any  of  the  three  mentioned  correspondents.  He 
asserts  that  he  has  "  seen  the  convulsions  of  dentition  fol- 
lowed by  prolonged  delirium  ending  in  idiocy,  or  in  true 

f  Clinical  Journal,  September  5,  1894. 
423 


DR.    JACOBI'S    WORKS 

epilepsy,  or  insanity  of  adolescents."  I  again  state  that  the 
convulsions  giving  rise  to  such  cases  of  epilepsy  are  called 
by  the  last  named  three  authorities  "  convulsions  due  to 
dentition."  Neither  Dr.  Blumer  nor  myself  go  that  far. 
I  speak  of  convulsions  only,  no  matter  from  what  cause,  and 
am,  therefore,  quite  prepared  to  accept  what  I  think  I  al- 
ways knew  and  proclaimed  to-day,  and  what  Dr.  Spratling 
expresses  in  a  concluding  remark,  "  that  the  spasms  and 
convulsions  of  infancy  are  serious  manifestations,  and  if 
allowed  to  go  unchecked,  may  lead  to  explosions  of  genuine 
epilepsy,  and  later  on  to  insanity." 

Now  what  is  dentition,  and  what  its  period  ? 

It  begins  during  uterogestation.  The  dental  sacs  of  the 
20  milk  teeth  undergo  ossification  in  the  fifth  month  of 
pregnancy.  Behind  them  are  the  sacs  for  the  permanent 
teeth.  Their  separation  from  the  former  is  not  completed 
until  the  fetus  is  born.  Before  and  after  birth  there  is  a 
constant  growth,  the  cartilage  of  the  wall  of  the  dental 
cavity  and  of  the  gums  disappears  gradually.  The  two 
lower  incisors  make  their  appearance  between  the  seventh 
and  eight  months,  the  upper  incisors  between  the  eighth 
and  tenth  months,  six  more  teeth  between  the  twelfth  and 
fifteenth  months,  four  bicuspids  between  the  eighteenth  and 
twenty-fourth  months,  the  four  second  molars  between  the 
twentieth  and  thirtieth  months.  The  second  visible  den- 
tition begins  about  the  fifth  or  sixth  year.  In  the  twelfth 
year  four  molars  make  their  appearance,  the  last  of  the 
whole  set,  with  the  exception  of  the  wisdom  teeth,  which 
protrude  between  the  sixteenth  and  twenty-fourth  year. 

Thus  the  period  of  dentition  begins  about  the  middle 
of  intrauterine  life,  and  ends  visibly  first  with  the  thir- 
tieth month,  and  secondly  with  the  twelfth  year.  It  is 
principally  the  first  which  is  charged  with  causing  or  being 
attended  by  convulsions. 

Convulsions  occur  almost  universally  between  birth  and 
the  thirtieth  month;  this  happens  to  be  the  period  of  denti- 
tion. But  it  is  also  the  period  of  defective  inhibition,  of 
nephritis,  otitis,  pneumonia,  enteritis,  and  infectious  and 
cerebral  diseases.  All  of  these  are  fruitful  causes  of  con- 
vulsions;   dentition    goes    on   during   that   period,   like    the 

4S4 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

growth  of  bones  and  hair  and  nails,  but  it  is  not  this  phy- 
siologic process,  but  those  morbid,  mostly  acute  changes, 
that  disturb  the  nerve  equilibrium. 

In  regard  to  convulsions,  infancy  may  be  divided  into 
two  periods.  One  comprises  the  first  two  months.  During 
that  time  reflex  action  is  insufficiently  developed.  That 
is  why  convulsions  at  that  time  are  almost  always,  perhaps 
always,  of  cerebral  origin,  and  caused  by  hemorrhages,  etc. 
The  other  begins  with  the  third  or  fourth  month.  About 
and  long  after  that  time  inhibition  is  insufficiently  devel- 
oped ;  that  is  why — while  convulsions  of  cerebral  origin  are 
not  excluded,  the  large  majority  are  of  a  reflex  nature.  The 
slightest  irritation  of  the  digestive  organs,  of  the  integu- 
ments, or  the  organs  of  circulation  gives  rise  to  spasmodic 
muscular  action  which  meets  with  no  control  on  account  of 
the  absence  of  nerve  inhibition.  The  difficulty  of  a  correct 
local  diagnosis  tempts  the  attention  in  the  direction  of  the 
known  process  of  dentition.  That  is  why  the  early  periods 
of  popular  and  of  professional  medicine — identical  in  so 
many  centuries — and  why  the  early  period  of  a  practition- 
er's life,  filled  as  it  is  with  the  lack  of  circumspect  experi- 
ence— are  replete  with  the  diagnosis  of  difficult  dentition,  or 
the  legend  of  the  dangers  of  normal  dentition,  which,  after 
all,  is  a  physiologic  process. 

During  the  first  year  or  two  years  of  life— that  means 
during  that  period  of  physiologic  dentition  which  is  most 
generally  noticed  by  even  the  superficial  observer,  remark- 
able changes  take  place.  The  heart  of  the  newly  born  and 
the  young  infant  is  comparatively  muscular  and  vigorous, 
the  carotid  (and  also  the  vertebral)  arteries  large,  the  blood 
supply  to  the  head  is  ampler  than  at  any  other  part  of  its 
life.  The  rapid  growth  of  the  head  and  brain  connected 
therewith,  or  rather  depending  thereon,  is  a  well-known 
fact.  The  salivary  glands  develop  rapidly,  their  and  the 
mucous  membrane's  over-secretion  begins  with  the  third 
month  and  is  not  the  result  of,  but  co-ordinate  with,  the 
later  appearance  of  the  teeth.  The  rapid  growth  of  the 
cortex  and  of  the  anterior  lobes,  greater  in  proportion  than 
that  of  the  rest,  explains  the  rapid  increase  of  the  infant 
intellect  and  the  motor  function.    Physiologic  hypereemia  is 

425 


DR.    JACOBI'S   WORKS 

very  apt  to  become  pathologic  on  slight  provocations,  the 
more  so  as  the  embryonal  character  of  the  brain  tissue 
changes  only  gradually  in  the  course  of  a  few  years.  These 
are  no  rrew  facts.  Even  in  a  book  on  "  Dentition  and  Its 
Derangements/'  New  York,  1862,  I  could  utilize  a  great 
many  anatomical  data,  confirmed  and  added  to  since,  when 
trying  to  find  for  dentition  its  exact  place  in  etiology.  My 
conclusions  of  40  years  ago  I  can  still  repeat.  There  is  a 
certain  amount  of  itching,  even  pruritus  of  the  gums ;  there 
is  a  vasomotor  disturbance  in  the  shape  of  one  or  two  flushed 
cheeks;  now  and  then  a  slight  muscular  twitching;  now 
and  then  a  rolling  of  the  eye  caused  by  the  incompetence 
of  the  muscles  of  accommodation  met  with  in  every  infant 
to  such  an  extent  that  strabismus  is  common  in  healthy 
babies;  but  when  I  said  in  1887  *  that  I  never  in  10  years 
saw  a  convulsion  due  to  dentition  alone  I  here  repeat  the 
statement  as  valid  for  additional  15  years.  Nor  is  diarrhoea 
a  symptom  of  dentition,  for  infants  either  at  a  healthy 
breast  or  on  well-selected  artificial  food  have  no  diarrhoea. 
Do  you  wish  another  instance  of  the  complete  disappearance 
of  dentition  from  the  etiological  horizon?  When  all  of  us 
were  50  years  younger  did  we  not  hear  of  "  dental  "  paral- 
ysis? Nowadays  we  do  not  even  permit  the  term  of 
"  essential  "  or  "  infantile  "  paralysis.  Poliomyelitis  does 
not  fall  back  upon  dentition  as  a  cause.  And  what  is  cor- 
rect in  the  case  of  paralysis  is  so  in  convulsion.  When 
a  convulsion,  the  first  appearance  of,  or  rather  the  cause 
of  consecutive  epilepsy  or  idiocy,  is  attributed  to  dentition, 
the  history  of  the  case  as  submitted  to  us  is  incomplete, 
or  our  own  diagnosis  is  at  fault. 

The  high  estimation  in  which  dentition  was  held  for- 
merly has  assumed  smaller  proportions,  even  among  the 
maternal  public.  They  do  not  insist  any  more  as  they  did 
when  you  and  I  were  40  or  50  years  younger  upon  having 
the  baby's  gums  lanced  over  conspiring  poor  little  teeth,  just 
as  little  as  they  are  clamorous  any  more  for  worm  medicines 
for  their  pets  to  the  former  extent.  The  doctors  who  know 
how  to  make  a  diagnosis  of  a  bronchitis,  pneumonia,  nephri- 

8  Intestinal  Diseases  of  Infancy  and  Childhood,  Detroit,  1887. 

426 


CAUSES    OF    EPILEPSY    IN    THE    YOUNG 

tis,  otitis,  or  a  toxic  infection  are  getting  too  numerous, 
and  the  diagnostic  atmosphere  is  gradually  becoming  puri- 
fied. 

Still,  it  is  claimed  that  it  is  difficult  to  arrive  at  a  diag- 
nosis of  the  occult  diseases  of  infancy.  If  the  difficulty 
is,  or  were,  actual,  there  is  a  remedy.  See  to  it  that  the 
clinical  advantages  of  our  medical  schools  be  so  numerous 
and  so  perfected  that  rro  young  or  old  doctor  is  in  a  position 
to  accumulate  more  ignorance  than  knowledge.  Convul- 
sions in  the  young  are  of  frequent  occurrence  in  every 
practitioner's  rounds.  To  treat  it  is  something;  to  prevent 
it  is  better.  This  very  day  the  number  of  infectious  dis- 
eases, with  their  high  temperatures  and  their  toxins;  the 
many  intestinal  disorders,  with  their  nerve  reflexes,  are  still 
all-powerful.  There  are  still  some  meningeal  affections  that 
are  not  always  fatal,  but  highly  dangerous  in  their  results. 
All  this  is  well  understood.  But  there  is  a  class  of  dis- 
eases which  leads  as  often  to  convulsions  as  any  other;  that 
is  nephritis.  I  cannot  help  emphasizing  the  fact  that  it  is 
common  in  the  newly  born  and  the  very  young  infant; 
that  infarctions  and  jaundice  are  a  frequent  cause;  enteri- 
tis, with  its  indican  and  its  toxins,  engenders  legions  of 
cases ;  coal-tar  medication  is  a  frequent  source  of  evil ;  ex- 
posure causes  some ;  infectious  diseases,  from  mild  varicella 
to  influenza  or  diphtheria  or  scarlatina,  a  great  many.  As 
the  diagnosis  is  easy  to  make,  requiring  the  examination  of 
readily  attainable  urine  only,  I  admit  that  the  failure  to 
arrive  at  a  diagnosis  is  a  constant  source  of  surprise  to  me. 
Convulsions  from  that  source  are  very  frequent,  and  the 
vast  majority  of  them,  with  their  possible  dreadful  conse- 
quences, could  be  avoided.  Many  a  case  attributed  to 
dentition  could  easily  be  recognized  as  nephritic. 

Among  the  important  constitutional  diseases  that  have  a 
great  tendency  to  convulsions  is  rhachitis,  not,  as  Gowers 
says,  on  account  of  the  late  general  development  caused 
by  it,  but  for  other  reasons.  His  own  words  are  as  follows: 
"It  is  impossible  to  doubt  that  the  dentition  convulsions 
are  a  definite  element  in  the  causes  of  epilepsy.  So  con- 
stant, moreover,  is  their  association  with  the  defective  de- 
velopment which  we  call   rickets   that  it  is   impossible  to 

427 


DR.    JACOBI'S    WORKS 

doubt  that  the  prevention  of  rickets  would  have  a  consider- 
able influence  in  the  prevention  of  epilepsy."  In  the  further 
course  of  his  remarks  he  defines  as  defective  development 
mainly  its  retardation  of  the  growth  of  the  bones,  empha- 
sizing much  less  its  influence  on  muscles,  lymphatics  and 
the   large  viscera. 

The  retardation  of  development  hurts  mostly  bone  and 
tooth  formation.  But  nobody  ever  claimed  that  when  a 
tooth  is  formed  and  protrudes  late,  it  is  for  that  reason  a 
source  of  irritation  and  convulsion.  The  minor  or  major 
attacks  of  convulsions  in  rhachitis  are  always  of  central 
origiit.  They  always  mean  the  hyperaemia  or  oedema  ac- 
companying the  rhachitical  softening  of  the  cranial  bones. 
When  rhachitis  is  limited  to  the  curvatures  of  the  extremi- 
ties, or  the  development  of  a  rosary  or  Harrison's  groove, 
with  ever  so  much  deformity,  compression  of  lungs,  annoy- 
ance of  the  heart,  and  dislodgment  of  the  liver  and  spleen, 
there  is  no  convulsion.  It  occurs  in  craniotabes  which,  after 
a  period  of  restless,  cephalic  perspiration  and  occip- 
ital baldness,  begins  with  the  third  or  fifth  month  of  life. 
It  is  attended  by  hyperaemia  and  oedema  of  the  galea,  skull, 
dura  and  pia  mater  and  brain,  not  infrequently  with  effusion 
into  the  ventricles.  These  central  changes  cause  many 
cases  of  tetany,  almost  every  one  of  laryngismus  stridulus 
and  a  great  many  of  the  attacks  of  convulsions.  Once 
started  they  return  at  uncertain  times,  and  generally  disap- 
pear with  the  recovery  from  rhachitis,  produced  by  proper 
food  and  hygiene^  fresh  air  and  phosphorus.  As  long  as 
they  last  they  share  the  dangers  of  every  attack  of  eclamp- 
sia, viz.,  oedema,  thrombosis,  hemorrhage.  Not  infrequently 
they  last  longer  than  the  rhachitis  that  caused  it.  I  do 
not  care  to  speak  of  a  convulsive  habit  and  to  explain  the 
subsequent  epilepsy  by  this  habit;  that  would  be  no  ex- 
planation, but  another  word  only  for  the  fact.  The  real 
explanation  is  afforded  by  the  objective  changes  in  the 
structure  of  the  intracranial  contents  caused  by  the  con- 
vulsive interference  with  the  circulation  of  large  and  small 
vessels. 

The  local  irritation  of  phimosis,  congenital  or  acquired, 
complicated  or  not  with  balanitis,  resulting  from  the  changes 

428 


CAUSES   OF   EPILEPSY   IN   THE   YOUNG 

of  smegma  or  retained  urine,  may  cause  erection,  sexual 
excitement  and  masturbation  in  the  youngest  infants.  Head- 
aches have  often  been  attributed  to  it,  perhaps  only  on  ac- 
count of  interrupted  sleep;  permanent  nervous  disturbances 
have  been  ascribed  to  it  30,  20  and  10  years  ago  more  often 
than  at  present.  Indeed,  a  London  neurologist  has  gone  so 
far  as  to  make  the  statement  that  in  25  cases  of  epilepsy  he 
found  congenital  phimosis  11  times.  In  the  same  way  the 
nosology  of  some  colleagues  of  our  own  country  at  one 
time  explained  spastic  hemiplegia,  polioencephalitis  and 
myelitis,  chorea,  catalepsy,  epilepsy,  contractures,  also  idi- 
ocy by  the  presence  of  phimosis.  Would  it  could  have 
been  true;  for  indeed  if  it  had  there  would  have  been  less 
paralyses,  less  epilepsies,  less  idiocies.  In  29  of  30  cases 
of  phimosis  condemned  to  be  operated  upon  I  find  gentle 
manipulation  sufficient  for  a  reduction  of  the  usually  slight 
ailment.  I  can  say,  however,  that  I  never  in  my  life  saw 
such  a  case  that  I  could  ascribe  to  phimosis,  and  never  a 
recovery  from  paralysis,  idiocy,  or  epilepsy  due  to  circum- 
cision. 

I  have  mentioned  phimosis  as  one  of  th-e  causes  of  mas- 
turbation, which  has  frequently  been  connected  with  epi- 
lepsy and  other  derangements  of  the  nervous  system.  Mas- 
turbation was  always  recognized  as  a  frequent  occurrence 
in  the  periods  of  puberty  and  adolescence,  but  very  rarely 
before  1875  in  infants  and  children.  Like  its  precursor, 
the  persistent  sucking  of  fingers,  it  is  often  semi-conscious 
action,  more  frequent  in  girls  in  earliest  infancy,  in  boys 
later.  Among  its  causes  are  manual  irritation  by  nurses, 
or  misfit  trousers,  featherbeds,  excess  of  animal  foods  and 
stimulating  beverages,  rancid  smegma  under  a  long  or  nar- 
row prepuce,  eruptions  on  the  penis,  preputial  adhesions, 
phimosis,  vaginal  and  vesical  catarrh,  or  vesical  Qr  renal 
calculi,  oxyuris,  constipation,  horseback  or  bicycle  riding. 
Unless  it  be  continued  too  long,  the  unconscious  infant  and 
child  does  not  permanently  suffer  from  masturbation  to 
the  same  extent  as  the  adolescent.  In  the  latter  I  am  certain 
that  epilepsy  resulted  from  the  habit  in  a  good  many  cases. 
Such  I  have  seen  getting  well  when  it  was  stopped,  and  un- 
der proper  treatment — bromides  a  short  time,  cold  water, 

429 


DR.    JACOBI'S    WORKS 

lupulin,  camphor^  and  other  roborants,  continued  for  years. 
Infants  and  young  children  are  not  so  punished,  except  ap- 
parently in  those  cases  in  which  masturbation  itself  is  the 
result  of  a  central  disease.  Goltz  places  the  erection  center 
in  the  cord  about  the  fourth  lumbar  vertebra,  others  in  the 
pedunculi  cerebri  or  the  medulla  oblongata.  It  is  quite 
possible  that  in  such  cases  in  which  epilepsy  follows  mas- 
turbation, both  may  be  of  the  sam-e  central  origin.  They 
are  both  probably  incurable,  and  neither  a  treatment  di- 
rected to  the  center,  nor  irritating  vesicatories  or  brutal 
and  vulgar  clitoridectomy  can  possibly  be  expected  to  have 
an  eifect.  Such  cases  of  masturbation  are  as  incurable  as 
the  vast  majority  of  central  epilepsy.  What  I  express  as 
my  opinion  of  clitoridectomy  is  also  valid  in  regard  to 
worse  methods.  Baker  Brown  is  dead,  Everett  Flood,  of 
Baldwinville,  Mass.,  appears  to  be  very  much  alive.®  He 
eulogizes  castration  and  circumcision.  The  former  was  per- 
formed on  20  males  and  two  females.  The  cases  were  re- 
ported at  the  meeting  of  the  American  Medical  Association 
at  Atlanta.  He  admits  that  castration  has  "  bitter  op- 
ponents "  of  the  same  class  that  is  "  howling  against 
vaccination."  I  do  not  howl  against  vaccination.  To  me 
it  is  a  wonder  that  the  criminal  law  of  Massachusetts  has 
not  yet  interfered  with  these  attempts  at  dealing  with 
masturbation  and  epilepsy,  both  of  which  render  the  con- 
sent to  be  mutilated  an  impossibility  on  the  part  of  irre- 
sponsible, unfortunate  sufferers. 

0  Atlantic  Med.   Weekly,  October  24,  1896. 


430 


TREATMENT    OF    ENURESIS 

The  incomplete  development  of  the  sphincters,  in  the 
infant,  results  in  the  involuntary  emission  of  urine  and  dis- 
charge of  faeces.  This  condition  prevails  a  year  or  two, 
and  is  not  attended  with  any  subjective  sensation,  or  sen- 
sitiveness. The  sphincter  ani  is  the  first  to  gain  sufficient 
strength  to  retain  the  contents  of  the  rectum;  debilitating 
diseases  occurring  in  later  years  may  restore  it  to  its  origi- 
nal incompetency.  The  sphincter  of  the  bladder  attains 
a  satisfactory  power  towards  the  end  of  the  second  year. 
When,  however,  its  infantile  condition  persists  beyond  that 
period,  both  the  urine  and  the  genito-urinary  organs  being 
fairly  normal,  the  involuntary  emission  of  urine  continues, 
particularly  during  sleep  (enuresis  nocturna),  not  infre- 
quently through  the  day  (enuresis  diurna),  or  both  in  the 
night  and  during  the  day  {enuresis  continua).  Many  of 
such  cases  get  well  spontaneously  about  the  period  of 
puberty,  when  the  whole  genito-urinary  apparatus  under- 
goes a  rapid  development.  In  some  the  functional  weak- 
ness, however,  persists  long  beyond  that  time.  Not  long 
ago  I  had  to  relieve  the  case  of  a  young  lady  of  eighteen 
who  was  getting  ready  to  marry.  Most  cases  are  observed 
between  the  third  and  the  tenth  year  in  both  boys  and 
girls,  but  the  majority  of  the  patients  between  the  eleventh 
and  the  thirteenth  year,  also  of  those  who  suffer  in  more 
advanced  years,  are  males. 

The  muscular  debility  of  the  neck  of  the  bladder  and  the 
internal  sphincter  (in  fact,  identical  organs)  is  sometimes 
but  a  part  of  a  universal  muscular  incompetency,  which 
is  found  among  different  classes  of  children.  Some  are 
slow,  dull,  and  stupid,  and  lacking  in  general  innervation; 
others  are  simply  anaemic,  ill  developed,  and  generally 
feeble;  there  are  some  whose  whole  vitality  appears  to  be 
expended  upon  their  intellectual  sphere:  they  are  smart, 
quick^  spirited,  excitable,  mentally  vigorous  though  easily 

431 


DR.    JACOBI'S    WORKS 

exhausted;  but  their  muscles  are  thin,  sensitive,  and  in- 
continence of  urine  is  frequent.  In  many  such  cases  the 
sexual  and  urinary  organs  are  quite  small.  There  are 
others,  however,  who  exhibit  no  parallelism  of  debility 
in  the  urinary  muscular  apparatus  and  the  muscle-supply 
of  the  whole  body.  In  them  there  may  be  great  muscular 
general  dovelopment,  and  the  neck  of  the  bladder  alone 
seems  neglected.  On  the  other  hand,  there  may  be  great 
muscular  power  about  the  sphincter  in  an  otherwise  feeble 
and  anaemic  body.  Thus,  no  certain  rule  can  be  established, 
and  the  diagnosis  of  the  exact  condition  of  things  may  be- 
come quite  difficult.  Still,  there  is  a  class  of  patients  in 
whom  the  complication  of  enuresis  with  general  muscular 
insufficiency  is  very  apparent.  Indeed,  young  men  who 
after  moderate  venereal  excesses  suffer  much  from  noctur- 
nal or  diurnal  seminal  emissions  (with  or  without  in- 
continence of  urine)  are  frequently  those  who  have  a 
positive  history  of  incontinence  during  their  childhood. 
In  them  the  whole  muscular  apparatus  was  defective;  and 
the  posterior  part  of  the  urethra,  when  narcotized,  as  it 
were,  during  sleep,  gives  way  before  the  gentlest  pressure 
on  the  part  of  the  expelling  muscle  of  the  bladder. 

Insufficient  innervation  has  been  alluded  to  as  a  cause 
of  incontinence.  Children  who  pass  urine  while  engaged 
in  eager  play  may  suffer  either  from  debility  of  the 
sphincter  or  from  want  of  mental  control.  Particularly 
in  diseases  of  the  nerve-centers,  with  sopor  and  slow  men- 
tal action,  and  where  the  development  of  the  reflex  ap- 
paratus is  slow  and  defective,  the  sphincter,  which  con- 
tracts normally  while  the  bladder  is  filling  up,  loses  its 
control.  Profound  sleep  is  said  to  promote  incontinence; 
still  all  children  have  that  profound  sleep,  and  but  a  small 
percentage  are  afflicted  with  incontinence.  Such  general 
constitutional  disorders  as  scrofulosis  and  rhachitis  have 
been  charged  with  producing  incontinence,  but  the  vast 
majority  of  scrofulous  and  rhachitical  children  do  not  suf- 
fer from  it.  Slow  carbonic-acid  poisoning  is  also  credited 
with  resulting  in  incontinence;  thus  it  is  that  G.  W. 
Major  and  Ziem  explain  the  incontinence  of  mouth-breath- 
ing children,  and  E.  Bloch  the  nervous  disposition,  rest- 

432 


TKUOMEST  or  ESTMIMS 


rilHHK 


I    b 

ft      ir 


DR.    JACOBI'S    WORKS 

same  effect  on  the  bladder,  and  diabetes  mellitus  operates 
by  both  the  large  amount  of  urine  and  the  alterations  in 
its  chemical  composition.  Cystitis  in  all  its  forms  adds 
to  the  irritability  of  the  detrusor:  it  is  a  frequent  cause  of 
incontinence  when  this  makes  its  appearance  in  children 
whose  micturition  was  normal  before.  Stone  in  the  blad- 
der has  the  same  effect.  Phimosis  and  tight  adhesion 
of  the  prepuce  may  produce  incontinence,  particularly  in 
those  boys  who  are  subject  to  frequent  erections.  The 
rest  of  the  urinary  organs  exhibit  the  same  influence.  Thus 
in  every  case  of  enuresis  with  uncertain  diagnosis  nephri- 
tis, pyelitis,  renal  calculus,  and  vaginal  catarrh  must  be 
searched  for.  As  a  result  of  incontinence  of  urine  the 
bladder  is  apt  to  be  very  much  contracted:  it  holds  but 
little,  and  thus  what  was  originally  the  result  of  incon- 
tinence becomes   an   additional   cause. 

Masturbation  is  not  an  uncommon  cause  of  incontinence 
of  urine.  I  believe  that  my  paper  on  the  subject  of  mas- 
turbation and  hysteria  in  infancy  and  childhood^  has  di- 
rected the  attention  of  the  profession  to  the  frequency 
of  the  habit  of  masturbation,  with  all  its  consequences. 
Now,  in  the  young  the  caput  gallinaginis  is  quite  large, 
and  Cowper's  gland  and  the  vesiculae  prostaticae  are  suffi- 
ciently developed  to  result  in  erections.  The  constant  irri- 
tation of  the  part  by  self-abuse  leads  to  a  chronic  in- 
flammation of  the  whole  prostatic  portion  and  the  neck 
of  the  bladder,  which  is  very  s'ensitive.  Infants  addicted 
to  the  habit  are  very  apt  to  escape  for  years  its  conse- 
quences as  exhibited  in  somewhat  advanced  children ;  these 
suffer  from  general  malaise,  dull  headaches,  alteration  of 
temper,  and  somnolence.  The  genital  organs  are  mostly 
changed.  The  external  parts — the  vulva,  the  scrotum,  and 
particularly  the  glans  penis — are  rather  enlarged,  and  the 
urine  is  sometimes  alkaline,  and  often  slightly  opaque  with 
mucus,  leucocytes,  and  spherical  and  oval  epithelia,  some- 
times even  spermatozoa. 

The  condition  of  the  rectum  must  be  carefully  examined 

1  Amer.  Jour,  of  Obstetrics  and  Diseases  of  Women  and  Chil- 
dren, February  and  June,  1876.     See  also  Vol.  Ill  of  this  work. 

434 


TREATMENT    OF    ENURESIS 

in  every  case.  The  plexus  pudendus  controls  both  it  and 
the  neighboring  organs;  the  pudendal,  perineal,  and  mid- 
dle and  inferior  hemorrhoidal  nerves  are  disturbed  over 
the  lower  portion  of  the  bladder  and  the  vagina.  Thus 
a  rectal  irritation  produced  by  the  retention  of  faeces, 
the  presence  of  a  fissure,  which  is  much  more  frequent 
in  infancy  and  childhood  than  is  generally  supposed,  and 
the  effect  of  worms  (mostly  oxyuris)  in  the  lower  end  of 
the  intestinal  tract,  are  among  the  more  common  causes 
of  incontinence. 

Serious  disorders  of  the  nervous  system,  such  as  epilepsy 
or  night-terrors,  are  also  among  the  causes  or  complica- 
tions of  incontinence.  They,  however,  and  particularly  the 
latter,  need  not  be  taken  as  causes  only;  in  many  cases 
the  night-terror  is  but  a  result,  co-ordinate  with  incon- 
tinence, of  some  distant,  frequently  digestive,  disorder. 

Treatment. — The  great  variety  of  the  causes  of  incon- 
tinence of  urine  requires  tact  and  discrimination  in  the 
selection  of  remedies.  General  anaemia  and  muscular  de- 
bility indicate  a  diet  carefully  selected  for  its  nutritious- 
ness  and  digestibility.  Gentle  massage  of  the  whole  body, 
sponging  with  alcohol  and  water  (1:6)  or  with  water,  and 
efficient  friction  with  thick  towels,  sea-bathing,  and  the 
use  of  medicinal  roborants,  such  as  iron  or  arsenious  acid, 
will  always  prove  beneficial.  The  elixir  peps.  bism.  et 
strychn.  of  the  National  Formulary  is  a  good  preparation 
for  use  in  insufficient  gastric  digestion,  with  atony  of  the 
stomach;  a  child  of  three  years  may  take  a  teaspoonful 
three  times  a  day. 

Attention  must  be  paid  to  the  capacity  of  the  bladder. 
In  every  case,  particularly  in  the  evening,  the  quantity 
of  fluid  must  be  restricted.  The  sigmoid  flexure  and  the 
rectum  must  be  empty  in  the  night,  and  patients  should 
be  encouraged  to  evacuate  both  bladder  and  rectum  before 
retiring.  After  a  few  hours'  sleep  the  children  ought  to 
be  taken  up  and  roused  sufficiently  for  both  purposes. 

Muscular  debility  of  the  neck  of  the  bladder  (sphincter) 
requires  general  and  local  stimulation.  Strychnine  or  other 
preparations  of  nux  vomica  prove  eff'ective  to  a  certain 
extent  by  improving  both  the  general  innervation  and  the 

485 


DR.    JACOBI'S    WORKS 

appetite;  in  desperate  cases  an  occasional  subcutaneous  in- 
jection into  the  perineum  (gr.  /4o"%6)  h^s  rendered  good 
service;  an  ointment  of  one  part  of  extract  of  nux  vomica 
in  from  ten  to  sixteen  parts  of  fat^  introduced  into  the 
rectum  (size  of  a  coii'ee  or  Lima  bean)  several  times  daily 
will  also  act  well  and  can  be  continued  for  some  time. 
The  same  indication  is  fulfilled  by  ergot,  the  fluid  or  the 
solid  extract  of  which  may  be  employed  internally.  The 
interrupted  electrical  currents  is  perhaps  the  most  power- 
ful local  stimulant;  one  of  the  eletrodes  must  be  applied 
to  the  perineum,  the  other  to  the  hypogastrium  or  the 
lumbar  region.  The  advice  to  apply  the  negative  pole  to 
the  interior  of  the  urethra  or  bladder  and  the  positive 
somewhere  externally  is  bad,  because  of  the  danger  of 
urethritis  and  cystitis. 

Whenever  there  is  oxalic  acid  or  sugar  or  an  excess  of 
urates  and  phosphates  in  the  urine,  the  source  of  the  dis- 
turbance must  be  attended  to.  The  digestive  disorders 
forming  the  source  of  the  anomalous  condition  require 
a  corresponding  change  in  the  diet  (diminution  of  nitro- 
genous food)  or  correction  of  the  functional  disorders  of 
the  stomach  and  liver.  Until  that  object  can  be  accom- 
plished the  prognosis  is  very  uncertain.  Vesical  catarrh, 
nephritis,  and  the  presence  of  a  calculus  in  either  the 
kidney  or  the  bladder  have  their  own  indications;  the 
consideration  of  which,  as  they  are  treated  in  other  parts 
of  this  volume,  is  here  omitted.  The  hypersesthesia  of  the 
body  of  the  bladder,  complicated  or  not  with  catarrh, — 
it  is  often  found  without  it, — requires  belladonna  or  its 
alkaloid.  Both  belladonna  and  atropine  are  tolerated  in 
much  larger  doses  by  children,  in  proportion  to  their  size 
or  age,  than  by  adults.  In  many  cases  a  single  evening 
dose  of  extract  of  belladonna  (gr.  :J— |— 1)  or  sulphate  of 
atropine  (gr.  /4oo~/45)  answers  well,  sometimes  to  an  un- 
expected degree.  Bromide  of  potassium  (gr.  vi-xxv),  cam- 
phor (gr.  ii-v),  extract,  humuli  fluidum  (min.  iv-x),  or  the 
elixir  humuli  of  the  National  Formulary  in  teaspoonful 
doses,  given  at  bedtime,  answer  a  similar  purpose. 

Causes  of  reflex  contraction  located  in  the  vagina,  penis, 
or  rectum  require  local  correction.  Vaginal  catarrh  is  as 
obstinate  because   of  its  inaccessibility  as  it  is   frequent. 

436 


TREATMENT    OF    ENURESIS 

Polypoid  excrescences  about  the  vagina  or  in  the  urethra 
(of  the  female)  must  be  removed;  if  there  be  phimosis, 
circumcision  is  required.  But  a  great  many  cases  which 
are  presented  for  that  purpose  could  easily  be  remedied 
by  gentle  dilatation  of  the  prepuce.  Firm  adhesion  of  the 
prepuce  requires  careful  detaching.  Intestinal  worms  must 
be  removed,  and  the  fact  remembered  that  oxyuris  has  its 
original  seat  in  the  upper  part  of  the  colon  and  the  lower 
part  of  the  ileum,  so  that  rectal  injections  have  but  a 
temporary  effect  in  most  cases.  Fissure  of  the  rectum, 
mostly  of  small  size  and  located  posteriorly,  requires  for- 
cible dilatation,  a  procedure  which  demands  no  time  and 
no  anaesthetic,  but  is  very  efficient. 

Irritability  of  the  neck  of  the  bladder  and  the  prostatic 
part  of  the  urethra  has  been  treated  by  Henry  Thompson 
with  cauterization  by  means  of  a  two-per-cent.  solution  of 
nitrate  of  silver.  A  solution  of  one  part  in  a  thousand 
of  distilled  water  will  be  found  sufficient,  or  a  solution 
of  one  or  two  parts  of  tannin  or  alum  in  a  hundred.  Still, 
it  is  a  better  plan  to  introduce  either  an  elastic  catheter 
or  a  metal  sound  into  the  bladder,  every  few  days,  for  two 
or  four  minutes.  A  few  drops  of  a  solution  of  cocaine 
instilled  into  and  distributed  in  the  urethra  a  few  minutes 
before  the  insertion  of  the  instrument  will  in  many  cases 
render  anaethesia  superfluous. 

The  latter,  however,  cannot  always  be  dispensed  with. 
In  the  case  of  a  girl  of  three  years,  with  chronic  catarrh 
of  the  bladder  and  incontinence,  anaethesia  was  required 
a  dozen  times,  for  two  purposes, — first,  to  inject  a  solution 
of  nitrate  of  silver  (1:1000)  into  the  bladder,  and,  sec- 
ondly, to  dilate  forcibly,  with  increasing  amounts  of  water, 
the  organ,  which  had  habituated  itself  not  to  hold  more 
than  a  few  drachms  of  fluid  at  a  time. 

Masturbation,  which  is  so  frequently  the  cause  of  irri- 
tation of  the  prostatic  portion,  has  its  own  indications.  Its 
cure  is  by  no  means  easy.  Infants  can  be  watched  and 
forcible  prevention  of  self-abuse  (mostly  by  the  thighs 
or  hands)  exercised;  but  children  of  more  advanced  years 
require  an  unusual  amount  of  firmness  and  supervision. 
Bodily  punishment  will  avail  but  little;  in  the  treatment 
of  incontinence  from  whatsoever  cause,  nothing. 

437 


RACHITIC  DEFORMITIES:  ETIOLOGY,  CLINI- 
CAL HISTORY  AND  LESIONS 

I  RISE  with  much  diffidence,  for  I  am  to  discuss  a  sub- 
ject with  which  you  are  familiarized  from  day  to  day. 
You  see  these  rachitic  deformities  so  frequently  that  I  am 
afraid  I  shall  repeat,  from  my  point  of  view,  things  which 
are  to  you  matters  of  daily  observation  and  experience. 

Our  subject  is  the  etiology  and  the  lesions  of  rachitic 
deformities.  By  way  of  introduction,  I  would  say  that 
rachitic  deformities  are  something  new  in  our  country. 
You  have  seen  so  many  of  them  that  undoubtedly  the 
younger  men  here  do  not  remember  the  time  when  there 
were  no  rachitic  deformities  in  this  country.  Thirty  years 
ago  there  was  no  rachitis,  except  very  rarely  a  stray  case. 
At  that  time,  when  I  spoke  of  rachitis  and  endeavored  to 
demonstrate  a  case  in  my  clinic,  I  had  to  hunt  consider- 
ably for  material  to  illustrate  this  condition.  When,  twenty- 
two  years  ago,  I  wrote  a  paper  on  the  first  cases  of  cranio- 
tabes  I  had  seen  in  New  York,  it  was,  with  the  exception 
of  one  by  Parry,  of  Philadelphia,  the  first  paper  on  this 
subject  ever  written  in  our  country.  The  subject  of  rachi- 
tis, therefore,  is  a  comparatively  novel  one.  Since  that 
time,  immigration  has  been  going  on,  and  the  poverty- 
stricken  people  from  the  slums  of  Europe  have  been  ac- 
cumulating here.  As  with  the  greater  facilities  for  trans- 
portation science  has  been  equalized  all  over  the  globe, 
so  poverty,  bad  air,  and  want  of  every  description  have 
equally  spread  constitutional  diseases  here.  •  Since  then 
we  have  seen  much  rachitis  here.  Thus  it  is  that  the 
treatment  of  rachitis  in  the  future,  although  it  will  al- 
ways  remain  medical,  will  also  be   a  social  question. 

The  principal  causes  of  rachitic  deformity  are  numerous 
— the  rapid  growth,  the  thick  epiphyses,  the  soft  diaphyses, 
the  condition  of  the  ossification  cartilage,  the  traction  of 

439 


DR.    JACOBI'S    WORKS 

the  muscles,  the  debility  of  the  muscles,  and  the  pressure 
of  the  atmosphere.  The  localitj^  where  the  deformities 
are  found  depends  largely  upon  the  intensity  of  growth. 
Growth  is  most  intense  in  the  j'oung  child — (1)  in  the 
cranium;  (2)  in  the  chest;  and  lastly  only  in  the  extrem- 
ities. I  recapitulate  only  what  you  all  know  when  I 
speak  of  the  rachitic  head,  with  the  thin  skin,  the  dilated 
veins,  and  the  open  sutures  and  fontanelles  for  two,  three, 
four,  or  even  nine  years,  as  I  have  seen  it.  The  edges  of 
the  sutures  are  irregular.  Such  a  head  is  usually  large — 
actually  larger  than  the  normal  head — relatively  it  is  very 
much  larger  when  compared  with  the  frequently  small 
body.  It  is  so  large  that  it  resembles  sometimes  the 
hydrocephalic  head.  Indeed  some  of  these  heads  are  to  a 
certain  degree  hydrocephalic;  some  are  entirely  so.  Most 
of  them  are  brachy-cephalic,  quadrangular,  with  depres- 
sion on  top.  In  a  peculiar  class  of  cases,  first  studied  by 
Virchow,  that  of  the  cretins  and  semi-cretins,  rachitis  is 
combined  with  a  premature  ossification  of  the  occipito- 
sphenoidal  synchondrosis.  In  this  condition  the  base  of 
the  skull  is  shortened.  At  the  same  time  there  is  a  deep 
grooving  of  the  root  of  the  nose,  the  eyes  are  widely 
separated  from  each  other,  there  is  shortening  of  the 
vomer,  and  the  flat  palate  so  characteristic  of  cretinoid 
conditions.  Not  infrequently  the  occiput  is  slightly 
flattened,  and  the  oblique  diameters  are  sometimes  not 
equal,  so  that  one  side  may  appear  to  be  entirely  flattened. 
This  is  particularly  the  case  when  we  deal  with  rickety 
softening  of  the  cranial  bones — craniotabes.  In  such 
cases  there  is  much  perspiration,  with  loss  of  hair  on  the 
occiput;  the  veins  are  more  dilated,  the  skin  thinner  and 
paler  than  in  the  average  head.  In  these  cases  of  cranio- 
tabes one  side  may  be  flattened  and  the  other  side  bulg- 
ing. The  head  may  even  appear  to  be  triangular.  Where 
one  side  bulges  out,  and  one  side  is  flattened  from  pres- 
sure, the  forehead  is  very  prominent,  sometimes  even  from 
three  to  five  times  its  normal  thickness,  because  of  an  im- 
mense amount  of  new  periosteal  soft  growth  between  the 
periosteum  and  the  bones,  which  produces  a  marked  de- 
formity of  the  forehead.     This  is  not  always  a  temporary 

440 


RACHITIC    DEFORMITIES 

affair.  It  is  true  that  craniotabes  may  leave  no  trace  if  it 
gets  well  sufficiently  soon,  but  when  there  is  much  de- 
posit under  the  periosteum,  it  will  sometimes  remain. 
When  calcification  takes  place  very  suddenly,  then  the 
thickening  of  the  bone  will  remain  unabsorbed  for  life. 
As  a  rule,  however,  most  of  such  thickenings  are  ab- 
sorbed. 

The  condition  of  the  teeth  is  certainly  one  which  should 
be  considered  in  connection  with  rachitic  deformity.  The 
teeth  appear  late  or  irregularly;  when  early,  the  intervals 
between  the  first  crop  and  the  second,  or  between  the 
second  and  the  third  are  very  long — sometimes  six,  eight, 
or  ten  months.  The  teeth  are  frequently  discolored,  and 
they  decay  very  easily.  Sometimes,  however,  we  find  in 
the  second  crop  that  the  teeth  are  very  hard  and  very 
yellow.  Not  infrequently  we  see  "  Hutchinson  teeth  "  in 
rachitic  children.  This  is  one  of  the  reasons  why  Parrot 
got  the  idea  of  explaining  every  case  of  rachitis  as  the  re- 
sult of  syphilis.  The  lower  jaws  are  short,  narrow  and 
very  low,  the  angles  very  sharp  and  prominent.  The 
alveolar  processes  turn  inward.  Thus,  the  teeth  of  the 
upper  jaw  do  not  cover  those  of  the  lower  jaw.  The  chin 
in  some  cases  is  very  low.  From  the  foregoing  remarks 
it  will  be  seen  that  well-marked  rachitic  heads  present  a 
very   peculiar  appearance. 

The  trunk  in  rachitic  persons  is  very  short.  The  clavicle 
shows  much  perisoteal  thickening;  it  is  very  frequently 
bent  forward  by  the  pulling  of  the  muscles,  and  there  is 
not  infrequently  an  infraction  between  the  middle  and  an- 
terior thirds. 

The  chest  is  the  seat  of  a  great  deal  of  deformity.  It  is 
frequently  triangular,  sometimes  quadrangular;  the  dor- 
sum is  flat  and  the  scapula  clings  to  the  body.  The  ribs 
being  soft,  form  a  groove  in  which  the  arms  are  frequently 
buried.  There  is  a  predominance  anteriorly.  On  account 
of  the  atmospheric  pressure  laterally  above  the  diaphragm, 
there  is  a  horizontal  groove,  called  "  Harrison's  groove." 
As  there  is  compression  above  the  diaphragm  the  lower 
ribs  stand  outward.  As  the  chest  is  compressed  laterally 
the   sternum  is   made   to   protrude,  particularly   about  the 

441 


DR.    JACOBFS    WORKS 

third  and  fourth  ribs,  and  the  antero-posterior  diameter 
is  lengthened.  The  ribs  are  prominent  at  the  ossification 
point.  On  the  cartilages  there  are  frequently  nodulations; 
a  complete  rosary  may  be  developed  quite  early.  I  have 
seen  it  at  the  age  of  two  months,  and  a  case  has  been  pub- 
lished in  which  there  was  a  complete  rosary  in  a  baby  of 
only  three  weeks.  In  these  extreme  cases  the  sternum 
is  flat,  and  the  manubrium  stands  out;  frequently  it  is 
pressed  down  above  so  as  to  stand  out  at  an  angle  at  its 
lower  end;  the  lower  end  of  the  sternum  may  be  retracted 
while  the  ensiform  process  protrudes. 

Kyphosis  is  very  frequently  seen  in  these  cases.  It  is 
often  but  an  exaggeration  of  the  normal  curvature.  Sco- 
liosis has  mostly  its  convexity  to  the  right  with  compen- 
sation above  and  below.  The  spinous  processes  are  very 
frequently  directed  to  the  concavity.  The  intercostal 
spaces  are  very  narrow  on  the  left  side,  because  there  is 
less  curvature  of  the  ribs,  and  the  ribs  are  bent  out. 

In  the  grown-up  woman  the  antero-posterior  diameter 
of  the  pelvis  is  shortened.  This  is  not  seen  to  the  same 
extent  in  the  babe.  In  the  normal  baby  the  pelvis  is  small 
and  the  sacrum  very  steep,  not  concave  as  in  the  adult. 
Therefore,  when  compression  has  taken  place  because  of 
softening,  it  is  still  smaller  so  that  often  it  is  quite  diffi- 
cult to  examine  the  pelvis  satisfactorily;  the  sacrum  may 
be  so  changed  as  to  give  rise  to  a  convexity  inward  and 
contraction  of  the  two  sides.  This  narrowing  may  be  due 
to  the  mere  fact  that  the  softened  bones  are  compressed 
on  the  pillow,  or  by  the  arms  of  the  nurse,  a  pressure 
which  is  slight,  it  is  true,  but  quite  sufficient.  In  very  mild 
cases  the  symphysis  is  changed  but  little.  In  a  number 
of  instances,  however,  it  will  be  found  to  be  bent  forward, 
and  thus  in  very  early  rachitis,  the  rachitic  pelvis  is  very 
similar  to  the  pelvis  deformed  by  osteomalacia.  This  is 
contrary  to  the  usual  description  in  the  books  on  ob- 
stetrics. 

The  extremities  suffer  in  different  ways,  in  all  their 
parts — the  epiphyses  and  diaphyses,  the  periosteum,  and 
the  epiphyseal  cartilages.  The  epiphysis  is  frequently 
thick  and  painful,  particularly  on  the  forearm  and  tibia. 

442 


RACHITIC    DEFORMITIES 

A  number  of  cases  of  so-called  "  growing  pains "  are 
simply  instances  of  rachitic  epiphysitis.  Sometimes  the 
thickening  is  very  considerable;  in  most  cases  it  is  uni- 
form, but  in  some  it  is  more  developed  laterally.  This 
is  particularly  the  case  on  the  upper  part  of  the  thigh. 
The  diaphysis  is  usually  bent.  Semi-fractures  take  place 
in  the  arm,  clavicle  and  legs  from  a  very  trifling  applica- 
tion of  force.  The  periosteum,  however,  being  soft, 
always  acts  as  a  shield  to  the  inflamed  bone  when  exposed 
to  the  danger  of  fracturing.  In  all  those  cases  in  which 
there  is  much  curvature,  particularly  in  the  lower  ex- 
tremity, the  concavity  is  inward,  and  on  the  forearm  and 
thighs  it  is  very  often  anteriorly.  The  difference  in  the 
direction  of  the  curvatures  depends  on  the  influence  of  the 
muscular  traction,  or  of  the  weight  of  the  body.  In  the 
very  young  the  concavity  of  the  lower  extremity  is  in- 
ward because  of  the  effect  of  the  flexor  muscles.  When 
the  bones  become  or  remain  soft  in  those  who  attempt 
to  walk,  the  weight  of  the  body  results  in  outward  curva- 
tures, and  lesions  of  many  kinds. 

The  ligaments  are  very  flabby,  and  give  rise  to  flat-:ft)ot 
in  children  that  stand  up  and  attempt  walking.  The  peri- 
osteum suffers  a  great  deal,  and  in  difl'erent  ways.  It  is 
softened  and  exhibits  a  thick  layer  of  rachitic  deposit.  Cal- 
cification occurs  in  time,  and  then  the  diaphysis  will  be 
much  thicker  and  harder  than  in  normal  conditions.  The 
bones  of  rachitic  patients,  when  recovered,  are  solid  and 
able  to  stand  a  great  deal  of  hardship  in  later  life. 

In  the  rachitic  periosteum  there  may  be  haemorrhages. 
Not  infrequently  in  bad  cases  of  rachitis,  and  in  those 
cases  which  in  the  course  of  general  illnutrition  develop 
purpura,  there  are  haemorrhages  under  the  periosteum  in 
the  lower  and  upper  extremities.  Many  such  cases  of 
decided  rachitis,  and  those  which  exhibit  similar  haemor- 
rhages without  being  marked  by  rachitis,  have  been  thrown 
together  under  the  heading  of,  in  this  country,  "  scurvy," 
and  abroad,  "  acute  rickets."  In  all  of  these  cases,  the 
children  are  ill-fed;  there  is  a  great  deal  of  pain  in  the 
lower  extremities  and  feet,  sometimes  with  and  some- 
times without  periostitis.     The  haemorrhages  will  heal  and 

443 


DR.    JACOBI'S    WORKS 

leave  a  thickening  in  part  of  the  cases.  Haemorrhage  of 
gums  is  not  a  requisite  for  the  diagnosis ;  it  may  be  absent 
in  those  who  have  no  teeth,  or  who  have;  and  present 
even  where  there  are  no  teeth. 

Finally,  deformities  consisting  of  shortening  of  the 
whole  limb  are  due  to  the  early  calcifications  of  the  epiphy- 
seal cartilages.  It  is  on  this  physiological  function  that 
the  length  of  the  diaphysis  depends.  When  calcification 
is  complete,  the  growth  of  the  bone,  and  that  of  the  limb 
ceases. 

I  wish  to  remind  you  that  rachitis  is  a  general  constitu- 
tional disease.  In  it  we  have  to  deal  not  only  with  the 
general  system,  particularly  with  another  part  of  the  loco- 
motor system — the  muscles.  The  muscles  suffer  just  as 
well  as  the  bones  in  rachitis,  and  give  rise  to  certain  de- 
formities. Both  voluntary  and  involuntary  muscles  are 
affected.  What  has  been  called  rachitic  pseudo-paraly- 
sis, is  not  paralysis ;  it  is  simply  a  weakness  of  the  muscles 
and  nothing  else.  We  should  have  been  spared  this  new 
term.  The  muscles  are  simply  poorly  developed,  and  in 
consequence  they  are  easily  fatigued.  The  involuntary 
muscles  suffer  in  the  same  way. 

While  the  muscular  tissue  is  poorly  developed,  fat  is 
liable  to  be  ample.  Rachitic  children,  unless  emaciated 
by  pulmonary  or  intestinal  diseases,  are  apt  to  be  heavy 
and  rotund,  and  their  weight  and  appearance  are  often 
mistaken  for  healthy  development.  But  they  are  flabby, 
anaemic,  and  not  capable  of  resisting  attacks  of  ordinary 
diseases  like  well  children.  They  prove,  moreover,  that 
weight  alone  is-  not  the  measure  for  healthy  and  steady 
evolution. 

The  muscles  in  such  subjects  are  flabby,  and  conse- 
quently the  stomach  is  apt  to  be  dilated,  and  the  muscu- 
lar layers  of  the  intestine  are  apt  to  yield,  thus  giving 
rise  to  large,  flabby  abdomens  filled  with  gas,  on  the  sur- 
face of  which  are  dilated  veins. 

The  expansion  of  the  intestines,  owing  to  the  weakness 
of  the  muscles,  gives  rise  to  constipation.  This  constipation 
is  characteristic.  Rachitic  children  become  constipated 
very  early.     It  is  sometimes  the  first  symptom  of  rachitis, 

444 


RACHITIC    DEFORMITIES 

and  shows  that  the  muscles  participate  in  the  process  at 
a  very  early  stage.  It  may  begin  at  the  second  or  third 
month  of  life  in  a  child  presenting  evidences  of  fairly  good 
nutrition ;  and  it  at  once  leads  us  to  suspect  rachitis. 
Some  deformity  of  the  abdomen  may  be  due  to  the  spleen, 
liver  and  kidneys.  In  consequence  of  "  Harrison's  groove  " 
the  liver  and  spleen  are  not  infrequently  displaced,  and 
these  organs  for  the  same  reason  may  appear  larger  than 
they  really  are.  The  kidneys  may  be  found  floating. 
Most  of  the  cases  of  floating  kidneys  occurring  in  children 
that  I  met  with  were  in  rachitic  children,  showing  Harri- 
son's groove  well  developed.  But  there  are  cases  in  which 
the  spleen  and  liver  are  actually  enlarged,  from  slow  con- 
gestion and  interstitial  hyperplasia.  They  cause  the  same 
deformity  that  is  occasionally  seen  in  syphilitic  subjects. 
This  is  another  reason  why  Parrot  came  to  the  conclusion 
that  every  case  of  rachitis  must  be  syphilitic. 


445 


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